(LS) #50 CG001 – COGH SPCA Electronic debit order mandate for a once-off or monthly donation to the Cape of Good Hope SPCA Email address* Enter email address Confirm email address Authority given by:First name*Surname*Date of birth* Town/city of residence*Cell no.*Bank account details:South Africa only.Select your bank*ABSA BANKCAPITEC BANK LIMITEDFIRST NATIONAL BANKFIRSTRAND BANKINVESTEC BANK LIMITEDNEDBANKSTANDARD BANKABSA-ITHALAAFRICAN BANKALBARAKA BANKBANK OF ATHENSBANK WINDHOEK BEPERKBIDVEST BANK LIMITEDCITIBANKDISCOVERY BANK LTDFBC FIDELITY BANK LTDGRINDROD BANK LIMITEDHABIB OVERSEAS BANK LIMITEDHBZ BANK LIMITEDHONGKONG & SHANGHAI BANKINGMERCANTILE BANK LIMITEDMTN BANKING(STANDARD BANK)NEDBANK LESOTHO LIMITEDNEDBANK LTD INC BOE BANKNEDBANK NAMIBIANEDBANK SWAZILAND LIMITEDPEOPLE BANK LTD INC PEP BANKPEOPLES BANK LTD INC NBSPERMANENT BANKSA POST BANK (POST OFFICE)SA BANK OF ATHENSSA RESERVESASFIN BANKSOCIETE GENERAL JHB BRANCHSOUTH AFRICAN POST OFFICESTANDARD BANK SWAZILANDSTANDARD CHARTERED BANK SASTANDARD LESOTHO BANK LTDSTATE BANK OF INDIASWAZILAND DEV AND SAVINGS BANKTHE ROYAL BANK OF SCOTLAND N.VTYME BANK LIMITEDUBANK LTDVBS MUTUAL BANKBranch code*Account number*Type of account*Current (Cheque)SavingsTransmissionAgreement:Abbreviated short name as registered with the acquiring bank: COGH SPCAReference*Your reference number will be generated on submission.I want to donate*MonthlyOnly this timeMonthly donation amount (please select)*R50 will help vaccinate and deworm an unwanted cat or dogR100 will help assist with the transport of a rescue animal in needR250 will help feed a dog for a monthR350 will help sterilise a dog or catR500 will help with the rescue of an injured animalMy own amountDonation amount (please select)*R50 will help vaccinate and deworm an unwanted cat or dogR100 will help assist with the transport of a rescue animal in needR250 will help feed a dog for a monthR350 will help sterilise a dog or catR500 will help with the rescue of an injured animalMy own amountMy own amount*Annual escallation Please increase my donation by 10% every year. MandateI/We hereby authorise COGH SPCA to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank on condition that the sum of such payment instructions will not differ from my/our obligations as agreed to in the Contract Reference Number. The individual payment instructions so authorised must be issued and delivered on the date when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not differ as agreed to in terms of the Agreement. I/We agree that the first payment instruction will be issued and delivered on:Start date for debit(s) to my account* and thereafter regularly on the:Monthly debit order day (please select)*1st7th15th20th25thLast dayof each month.Terms of agreementIf the date of the payment instruction falls on a weekend or public holiday, I agree that the payment may be debited against my account on the following business day; or subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid or until this authority is cancelled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post to Cape of Good Hope SPCA, P O Box 3, Plumstead, 7801. 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 cancel the Agreement. I/We also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate if such amounts were legally owing to you. 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.Newsletter Please send me updates and news about the SPCA's work. Signature*Signature verified by Bank This iframe contains the logic required to handle Ajax powered Gravity Forms.