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Your HALT Account Number
Your Name / Company Name
ID Number / Company Reg. Number
Company VAT Number
Your Email
Street Address
Address Line 2
City
Contact Number
ZIP / Postal Code
User 1
User 2
User 3
User 4
User 5
This is a password used when our Control Room contacts you once we have received a panic signal from the mobile panic button app to verify that we are speaking to the account holder and that everything is safe and secure.
Password
Medical Aid Name
Medical Aid Main Member's Name
Medical Aid Number
Ambulance Service
Armed Response Company
I agree to HALT Group Terms & Conditions YESNO
Account Holder Name
Bank Name
Account Type
Branch Code
Account Number
If the amount to be paid or payment dates change HALT Group will notify you in writing in advance of your account being debited or as otherwise agreed. If HALT Group or your bank makes an error, you are guaranteed a full and immediate refund from HALT Group of the amount paid.
Debit Order Effective Date
I hereby instruct and authorise HALT Group to draw against my bank account the payment required in terms of my service agreement on the 1st day of each month and continuing for the duration of this service agreement. I undertake against the said bank that I shall regard receipt and acknowledgement by HALT Group of this request, as receipt and acknowledgement by the bank.
ResidentialBusiness
Title (required)
MrMrsMissProfDr
Your Name (required)
Your Email (required)
Cellphone
Company
Your Message
