Declaration and Undertaking

I hereby confirm that all the information provided above is true and correct. I undertake to notify Deon de Lange Dental Supplies/Lab in writing of any changes to the information supplied within 14 (fourteen) days of such changes. I accept full responsibility for the account and acknowledge that, should payment not be made within the agreed payment terms, my details may be listed with the ITC as a defaulting debtor. Furthermore, I understand and agree that in the event of non-compliance with the above undertaking, I will be held liable for all outstanding amounts, as well as any and all legal costs incurred in the recovery thereof, including but not limited to attorney-and-client fees, collection commission, and tracing costs.