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Order Form:

Section 1: Personal Information

Name:
Surname:
Company:
Company Reg No:
Company VAT No:
Physical Address:
Postal Address:
Telephone:
Fax Number:
Email Addess:

Section 2: Products

I hereby order the following products:

Constant Contact Email Marketing System Management
SMS Marketing Additional Users
Voucher Module Website Deign/Development
Web Hosting    

Section 3: Debit Order Info

Bank Name:
Branch:
Branch Code:
Account Number:
Account Type:
Preferred day of month:

I / We hereby authorise Certech, utilising the services of a third party data bureau, to draw against my/our account (Specified in Section 2 Above), an amount as determined and agreed to in my/our agreement with Certech on or around the date mentioned in Section 2 above of every month until termination of the contract by either party.

This authority may be cancelled by me / us by giving Certech one month (30 days) written notice.

I/We understand that Certech will not refund any amounts which Certech may have withdrawn whilst this authority was in force if such amounts where legally owing to Certech.

I / We agree to pay any Bank Charges relating to this debit order instruction and also understand that each withdrawal will be reflected on my/our bank statement and will be identified by Certech in the reference field.

I / We acknowledge that the party hereby authorised to effect this drawing against my/our account may not cede or assign any of it's rights to any third party without my/our prior consent and that I/We may not delegate any of my/our obligations in terms of this contract / authority to any third party without prior written consent of the authorised party

I /We have read, understand and accept the Certech Terms and Conditions.

 
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