Membership Form for Body and Mind
Body and Mind is an online health directory for professionals. Our site advertises and markets all health and healing modalities.
We started in April 2000 and have grown from strength to strength over the years.
Tel: 083 677 1123
We are the largest and busiest online alternative health directory in South Africa.
Please do not fill this form out on your phone. Use your computer / desktop.
Body and Mind Membership Agreement:
Abbrev. Name with bank: BODYNMIND
A. Authority: Given by (name of account holder)
Company Name (optional)
Contact Email address
Accounts Email address
Web Site (if you have one)
Skype address for your interview
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Trinidad and Tobago
Bosnia and Herzegovina
United Arab Emirates
Papua New Guinea
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Sao Tome and Principe
United Republic of Tanzania
Country / Region
What you get for my once off set up fee?
Please choose which option suits you better.
R1500 includes a mailshot to 1 group
1. Initial consultation (telephonic or skype)
2. Market research with optimised keyword search.
3. Set up and design of Body and Mind webpage and Googlemap.
4. Set up of your own admin section complete with username and password
5. Branding discussion
6. Setting up events link so that all events display on your page
7. Setting up personalized photo Gallery and Testimonial page
8. A 10 Minute recorded audio interview which can be used as an advertising tools during future campaigns.
9. Announcement with photo in the following Body and Mind newsletter of your new member status.
Marketing of your interview on our social media platforms and our newsletter.
Amount R85-00 to be debited on the 28th of each month will be the membership fee on www.bodyandmind.co.za plus additional requested services for that month.
Please tick if you would like to be added to our Blog site (www.bodyandmindblog.co.za) and Mobile Phone App – R50 per month
R50 for APP
No thank you.
Branch name and code
Type of Account
This signed Authority and Mandate refers to our contract dated (“the Agreement”).
I/We hereby authorise you to issue and deliver payment instructions to your Banker for collection against my/our above-mentioned account at my/our 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/our obligations as agreed to in the Agreement and commencing on the below date and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of not less than one calendar month.
Terms and Conditions:
The individual payment instructions so authorised to be issued must be issued and delivered as follows:
Monthly: In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next ordinary business day.
I/We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks. I also understand that details of each withdrawal will be printed on my Bank statement. Such must contain a number, which must be included in the said payment instruction and if provided to me should enable me to identify the Agreement. This number must be added to this form in Section E before the issuing of any payment instruction.
B. 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.
I/We agree to pay any penalty bank charges relating to this debit order instruction.
C. Cancellation: I/We agree that although this Authority and Mandate may be cancelled by me/us with a 30 day notice of cancellation, 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.
D. 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.
E. Agreement Reference Number:
[First 10 letters of your name, NO SPACES] eg. BODYANDMIN (Total 10 characters)
*EFT Users may not use the tracking option and must exclude the option from their Authority and Mandate.
I agree that this serves as my digital signature as I enter into an agreement with Body and Mind to debit my account.
Please fill in your name
Signed at (area)
A Captcha sometimes appears for security reasons. It needs to complete and show a TICK before you push the submit button. Otherwise it will clear your whole form and leave it blank. It only appears sometimes.