Join – Scooter Angels Designated Drunk Driver Service for Take Me Home

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Customer Details *

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Last

South African ID Number *

Select Your Membership option *

*Most popular* Saver Plan Option 1 (R600 once-off via EFT for a 1 YEAR MEMBERSHIP. Save R588!)
SAVER PLAN Option 2 R99 per month via debit order)
CLASSIC PLAN (R199 per month via debit order)
CLASSIC PLAN FOR DISCOVERY INSURE MEMBERS (R60 per month via debit order)
PARTNER PLAN (R499 per month via debit order)

Address *

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Postal Code *

Cellphone number *

Email *

Confirm Email *

Make of PRIMARY VEHICLE USED (You can use our services with any other of your insured vehicles. *

Make

Model *

Model

Colour *

Colour

Vehicle Reg No *

Insurance Company Name *

Emergency Contact Person's Name *

Emergency Contact Person's Number *

Promotional Code (Optional)

Bank (NO CREDIT CARD DETAILS) *

Account Holder Name *

Account Type: cheque/savings [no credit cards] *

Account Number *

Branch Code *

How did you hear about us? *

Agree *

Agree

I hereby authorise you to issue and deliver payment instructions to your Banker for collection against my abovementioned account at my above-mentioned Bank (or any other bank or branch to which I / we may transfer my / our account) on condition that the sum of such payment instructions will never exceed my obligations as agreed to in the Agreement and commencing today and continuing until this Authority and Mandate is terminated by me by giving you notice by email of not less than 20 ordinary working days
The individual payment instructions so authorised to be issued must be issued and delivered on the last working day of each month.
I / We understand that the withdrawals hereby authorized will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction.
Abbreviated Name as Registered with the Bank: SCOOTER AN
Mandate
I / We acknowledge that all payment instructions issued by you shall be treated by my / our above-mentioned Bank as if the instructions have been issued by me/us personally.
Cancellation
I / We agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you.
Assignment
I / We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.

I hereby acknowledge that I am 18 years or older, have read and understand the below Terms & Conditions. *

Agree

Electronically signed and accepted on *

Signature *