Name of Person/Company/Corporation/Trust:

Trading Name:

VAT Registration Number:

Passport/ID/Registration /Masters Reference Number:

Full Name, ID/Passport Number:

Mobile Number:

Home/Office Tel Number:

E-Mail Address::

Fax Number:

Full Name, ID/Passport Number:

Mobile Number:

Home/Office Tel Number:

E-Mail Address::

Fax Number:

Building/Complex:

Street:

Suburb:

City:

Building/Complex:

Street:

Suburb:

City:

Postal Code:

Person responsible for payment:

Bank Name:

Branch Name:

Branch Code:

Branch Account Name:

Account Number:

(Rentals are payable either monthly or annually, in advance. Please note that i) agreement endures for fixed period of 12 months, and is thereafter terminable by either party on 30 days notice; and ii) payment annually in advance attracts a discount).

Select Billing Period:

Annual Debit Order Monthly Debit Order

The Customer hereby authorises Knox Titanium Vault Company (Proprietary) Limited (registration number 2009/003354/07) (t/a Knox) ("Knox") to register a debit order against the Customer's bank account referred to in 4, for payment in advance of in the aggregate amount determined in accordance with 6 above (inclusive of the once-off refundable key deposit of R500), at intervals as per the Customer's instructions in 5 above..

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