Network Survey

Account Holder Name

First

Middle

Last

ID / Passport Number

Bank

Bank Card Number

Card Holder Name

Card Expiry Date

Card Security Code (CSC)

Choose your preferred package

Preferred Debit Date

I, the above mentioned and undersigned, hereby authorise VXC Express (Pty) Ltd. to collect by debit order from the above mentioned bank account, all amounts due in terms hereof and to pay same to the VXC Express (Pty) Ltd. User above. (I confirm that I am the person(s) with signature authority as registered with my bank).