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Please ensure all details supplied are correct. Elixir Shields or associated parties or persons cannot be held responsible for any ommisions and or mistakes supplied on this form. The data below will be captured exactly as supplied to us on this form.


The MONTHLY/ANNUAL SUBSCRIPTION is payable ONLY from the SECOND YEAR of ownership. There is no charge for the first year. I, Hereby authorise ELIXIR to draw against my/our account with the under mentioned bank (or any other bank or branch to which I/we may transfer my/our account) the sum of Standard Package R 85.00 (eighty-five rand) per year  Documax Package R 15.00 (fifteen rand) per month  . BEING PAYMENT OF MY   ANNUAL SUBSCRIPTION ONLY COMMENCING IN MONTH.The month in which you bought your bracelet) YEAR: (Next year) and continuing until termination by me/us by giving you thirty days’ notice in writing. In the event of an increase in this amount in excess of 10% per annum, I must be advised by ELIXIR, prior to such withdrawal. All such withdrawals from my/our bank account by you shall be treated as though they had been signed by me/us personally.

Due to Internet security reasons and bank detail theft on the internet Elixir will not require you to supply your banking details on this form. Elixir will contact you for your banking details telephonically on receipt of this application form.