Credit Card Payments:

CONSENT TO DEDUCTION OF MONEY FROM CREDIT CARD
Print, sign and fax back to (013) 755 1270
Please note that fields denoted with (!) are required fields.

I, the undersigned:

Name:

Surname:

ID Number:

Postal Address:

Physical Address:

Mobile Phone:

Work Telephone:

Home Telephone:

Fax:

E-Mail Address:

I hereby agree, and acknowledge the following: (Tick the box on the left to agree)

That I authorize BetSA to deduct the amount of R ! from my credit card.

That I owe BetSA the above amount until authorization of this amount has been received from the credit card division.

Should I have consented to the deduction of any money from my budget account, the amount will be deductible, and payable over a period of !

I further confirm that my credit card details are as follow:

CREDIT CARD INFO:

CARD NUMBER:

EXPIRY DATE:

LAST 3 DIGITS ON BACK OF CARD

!	I confirm that the information that is set out above, is correct, and that I have been granting this permission voluntary, without any undue influence being placed on myself

Signed ! on this of 2004

Signature ____________________________

Please print and fax back to (013) 755 1270