About us Personal detailsAll fields marked with * is mandatory - select your title * -Mr.Mrs.Miss.- select your title * -Field is required!Field is required!Your First Name *Field is required!Field is required!Your Last Name *Field is required!Field is required!Your ID Number *Field is required!Field is required!- Preferred language * -EnglishAfrikaansZuluXhosa- Preferred language * -Field is required!Field is required!Contact detailsYour personal cell no.Field is required!Field is required!Your home landlineField is required!Field is required!EmailField is required!Field is required!Residential address detailsYour unit numberField is required!Field is required!Your complexField is required!Field is required!Your street noField is required!Field is required!Your street/farm nameField is required!Field is required!Your suburb/districtField is required!Field is required!Your city/townField is required!Field is required!Your postal codeField is required!Field is required!Postal address detailsYour P.O. BoxField is required!Field is required!Your post officeField is required!Field is required!Your postal codeField is required!Field is required!Employment detailsYour employer nameField is required!Field is required!Your position heldField is required!Field is required!Your work phone numberField is required!Field is required!Emergency contact detailsEmergency contact 1 details- select emergency contact 1 title -Mr.Mrs.Miss.- select emergency contact 1 title -Field is required!Field is required!Emergency contact 1 first nameField is required!Field is required!Emergency contact 1 last NameField is required!Field is required!Emergency contact 1 relationshipField is required!Field is required!Emergency contact 1 D.O.B or ID NumberField is required!Field is required!Emergency contact 1 cell noField is required!Field is required!Emergency contact 1 emailField is required!Field is required!Emergency contact 2 details- select emergency contact 2 title -Mr.Mrs.Miss.- select emergency contact 2 title -Field is required!Field is required!Emergency contact 2 first nameField is required!Field is required!Emergency contact 2 last NameField is required!Field is required!Emergency contact 2 relationshipField is required!Field is required!Emergency contact 2 D.O.B or ID NumberField is required!Field is required!Emergency contact 2 cell noField is required!Field is required!Emergency contact 2 emailField is required!Field is required!Medical detailsYour medical aid providerField is required!Field is required!Your medical policy numberField is required!Field is required!Your medical aid contact noField is required!Field is required!Name of your doctorField is required!Field is required!Your doctors contact noField is required!Field is required!Your blood groupField is required!Field is required!Jewish (No blood card)Field is required!Field is required!Organ donorField is required!Field is required!Disabilities:Field is required!Field is required!(If yes please provide more information)Field is required!Field is required!Your medical conditionsField is required!Field is required!Your allergiesField is required!Field is required!Vehicle detailsVehicle 1Vehicle 1 makeField is required!Field is required!Vehicle 1 model(series)Field is required!Field is required!Vehicle 1 body type e.g. SedanField is required!Field is required!Your vehicle 1 yearField is required!Field is required!Your vehicle 1 colourField is required!Field is required!Your vehicle 1 registrationField is required!Field is required!Your vehicle 1 tracking companyField is required!Field is required!Your vehicle 1 insurance providerField is required!Field is required!Your vehicle 1 policy noField is required!Field is required!Vehicle 2Vehicle 2 makeField is required!Field is required!Vehicle 2 model(series)Field is required!Field is required!Vehicle 2 body type e.g. SedanField is required!Field is required!Your vehicle 2 yearField is required!Field is required!Your vehicle 2 colourField is required!Field is required!Your vehicle 2 registrationField is required!Field is required!Your vehicle 2 tracking companyField is required!Field is required!Your vehicle 2 insurance providerField is required!Field is required!Your vehicle 2 policy noField is required!Field is required!Security company detailsYour security company nameField is required!Field is required!Your security company telField is required!Field is required!Product seletionAAA Response Premium Membership (R30,00) *Minimum Product RequirementAdvanced CoDriver Assistance (R47,77)Code Red (R27,77)Field is required!Field is required!Banking debit order instructionsYour monthly membership feeField is required!Field is required!I/We request and authorize you to debit my/our account on the 25th 1st 7th 15thI/We request and authorize you to debit my/our account on the 25th 1st 7th 15thField is required!Field is required!25th1st7th15thField is required!Field is required!at the bank/branch mention below. My/Our account details for payment are as follows:at the bank/branch mention below. My/Our account details for payment are as follows:Field is required!Field is required!Bank account detailsAccount holder nameField is required!Field is required!Bank nameField is required!Field is required!Account no.Field is required!Field is required!Account typeField is required!Field is required!Branch nameField is required!Field is required!Branch codeField is required!Field is required!Signed atField is required!Field is required!On thisField is required!Field is required!Day ofField is required!Field is required!YearField is required!Field is required!Name of signatoryField is required!Field is required!Field is required!Field is required!I herby grant authority to Trackbox Technologies (Pty) Ltd to act on my behalf and activate the Electronic mandate, which will initiate the Debit Order as per this signed document.I herby grant authority to Trackbox Technologies (Pty) Ltd to act on my behalf and activate the Electronic mandate, which will initiate the Debit Order as per this signed document.Field is required!Field is required!Terms and Conditions (Agreement)The signed Authority and Mandate refers to our contract as dated on signature hereof (“the agreement”). I/We hereby authorise you to issue and deliver payment instructions to the bank for collection against my/our above mentioned account at my/our above mentioned bank (or any other bank or branch to which I/We transfer my/ our account) on condition that the sum of any outstanding amount on my account, and commencing on the date stipulated and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your email address indicated above. The individual payment instructions so authorised must be issued and delivered as follows; On the ( 25th/1st/ 7th/ 15th) day (‘payment day’) of each and every month commencing onThe signed Authority and Mandate refers to our contract as dated on signature hereof (“the agreement”). I/We hereby authorise you to issue and deliver payment instructions to the bank for collection against my/our above mentioned account at my/our above mentioned bank (or any other bank or branch to which I/We transfer my/ our account) on condition that the sum of any outstanding amount on my account, and commencing on the date stipulated and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your email address indicated above. The individual payment instructions so authorised must be issued and delivered as follows; On the ( 25th/1st/ 7th/ 15th) day (‘payment day’) of each and every month commencing onField is required!Field is required!Select a dateField is required!Field is required!In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the ordinary business day prior to the payment day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account. I/We understand that the withdrawals hereby authorised 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. I/We shall not be entitled to any refund of the amount which you have withdrawn while this authority was in force, if such amount was legally owing to you. MANDATE I/We acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned bank as if the instructions had 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 nullify 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. LIABILITY It is expressly agreed that the services rendered are for the purpose of preventing or minimizing the loss or damage to property and injury to persons by means of crime, emergency situations or medical problems and the Contractor gives no guarantee that such services will be able to prevent or minimise such loss, damage or injury. It is therefore agreed that the TrackBox Technologies (Pty) Ltd and its service delivery partners and associates will not be held responsible for any loss, damage, injury or consequential loss of whatsoever nature arising from crime, emergency situations or medical problems. The client and/or members indemnify TrackBox Technologies (Pty) Ltd and all of its service delivery partners and associates against any claim of a third party, regarding legal liability arising out of TrackBox Technologies (Pty) Ltd and all of its service delivery partners’ acts or omissions.In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the ordinary business day prior to the payment day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account. I/We understand that the withdrawals hereby authorised 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. I/We shall not be entitled to any refund of the amount which you have withdrawn while this authority was in force, if such amount was legally owing to you. MANDATE I/We acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned bank as if the instructions had 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 nullify 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. LIABILITY It is expressly agreed that the services rendered are for the purpose of preventing or minimizing the loss or damage to property and injury to persons by means of crime, emergency situations or medical problems and the Contractor gives no guarantee that such services will be able to prevent or minimise such loss, damage or injury. It is therefore agreed that the TrackBox Technologies (Pty) Ltd and its service delivery partners and associates will not be held responsible for any loss, damage, injury or consequential loss of whatsoever nature arising from crime, emergency situations or medical problems. The client and/or members indemnify TrackBox Technologies (Pty) Ltd and all of its service delivery partners and associates against any claim of a third party, regarding legal liability arising out of TrackBox Technologies (Pty) Ltd and all of its service delivery partners’ acts or omissions.Field is required!Field is required!Signed atField is required!Field is required!On thisField is required!Field is required!Day ofField is required!Field is required!YearField is required!Field is required!Name of signatoryField is required!Field is required!Field is required!Field is required!Submit