(LS) #28 DA002 – Democratic Alliance (FR) FEDERAL HEAD OFFICETel: +27 21 465 1431Fax: +27 21 466 8394Email: [email protected]www.da.org.zaP.O. Box 1475, Cape Town, 8000DEBIT ORDER INSTRUCTION OTP VerificationPayment amount*R25R50R100R250R500R1000Other payment amount*Please enter a number greater than or equal to 50.Amount in numeralsMonthly debit order day*1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31stStart date for first debit to my account* Date Format: DD slash MM slash YYYY PERSONAL DETAILSName* First Last ID number*Telephone (Home)Telephone (Work)Cellphone*FaxEmail* Enter Email Confirm Email Address* Street Address Suburb City Province Postal Code PAYMENT METHODPay using?*Bank accountCredit cardBANK ACCOUNT DETAILSName of account holder*Name of 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 BANKINGHSBC BANKOM BANK LIMITEDCAPITEC BUSINESSMTN 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 BANKFINBOND MUTUAL BANKACCESS BANKBANK OF CHINABANK ZEROBNP PARIBAS SA SOUTH AFRICACHINA CONSTRUCTION BANKFINBOND NET1ICICI BANK LIMITEDJ.P.MORGAN CHASE BANK N.ASOCIETE GENERALEBranch nameBranch code*Account number*Account type*CurrentSavingsTransmissionCREDIT CARD DETAILSCredit Card DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name AGREEMENTAbbreviated short name as registered with the acquiring bank: DANHORefer to our contract reference number (“the Contract Reference Number”):Reference*Terms of agreementThis signed Authority and Mandate refers to our contract as dated as on signature hereof ( "the Agreement" ). I/We hereby authorise you to issue and deliver payment instruction to the bank for collection against my/our below mentioned account at my/our below 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 instruction will never exceed my/our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of no less than 20 ordinary working days. The individual payment instructions so authorised to be issued must be issued and delivered as follows: On the "Payment day" of each and every month commencing on "Start date" 2016. In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account. I / We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. 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. Abbreviated name as registered with the bank: DA52 CURR MANDATE I / We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned 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 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. ASSIGNMENT I / We acknowledge that this Authority may be ceded to 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.POPI disclaimerI agree to allow the Democratic Alliance to process my information for a lawful purpose, in line with the DA’s activities. The DA will never share your information with a third party. To view our Privacy Policy and PAIA manual please follow this link : https://www.da.org.za/get-involved/privacyOpt in options YES, I want to receive DA NEWSLETTERS YES, I want to become a DA Member YES, you may call me for future campaigns Fundraiser Name*Fundraiser ID*Fundraiser Province*Fundraiser Email Address*Signature*Signature verified by Bank
