E-Mandate

Electronic debit order mandates for your business.

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(LS) #40 GPA001 – GREENPEACE

Electronic debit order mandate

OTP Verification
Admin Only
- Skip OTP Verification
If you're not receiving an OTP you may skip the verification and continue to signing the E-Mandate by clicking "I accept the agreement" button below.
Admin Only
- Skip OTP Verification
If you're not receiving an OTP you may skip the verification and continue to signing the E-Mandate by clicking "I accept the agreement" button below.
Fundraiser Name*
Fundraiser Name*
Fundraiser ID
Recruitment City
Recruitment Venue*
Existing Reference*
Source of Lead
Supporter Pack*
- Yes
- No
Authority given by:
Name*
Title First Last
Designation
Address*
Postal Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Landline Number
Work Number
Cellphone Number*
Preferred Contact Time*
- 08:00-10:00
- 10:00-12:00
- 12:00-14:00
- 14:00-16:00
ID Type*
- RSA ID
- Other
ID Number*
Other ID*
Date of Birth*
Date Format: DD slash MM slash YYYY
Are you over 25 years old?*
- Yes
- No
Are you over 21 years old?*
- Yes
- No
Are you over 25 years old?*
- Yes
- No
We unfortunately do not accept donations from anyone under 25 years of age.
We unfortunately do not accept donations from anyone under 21 years of age.
We unfortunately do not accept donations from anyone under 25 years of age.
Payment Type*
First donation received via POS?*
- Yes
- No
POS details:
Receipt Number*
Bank account details:
Bank*
Branch code*
Account number*
Type of account*
Agreement:
Abbreviated short name as registered with the acquiring bank: GREENPEACE
Refer to our contract reference number (“the Contract Reference Number”):
Reference*
I want to donate*
- Monthly
- Quarterly
- Once-off
Contract amount*
- R120
- R150
- R200
- R250
Contract amount
- R120
- R150
- R200
Contract amount*
Please enter a number greater than or equal to 300.
Contract amount*
Contract amount*
Please enter a number greater than or equal to 180.
Contract amount*
Please enter a number greater than or equal to 180.
Contract amount*
Please enter a number greater than or equal to 300.
Contract amount*
Please enter a number greater than or equal to 250.
Contract amount*
Please enter a number greater than or equal to 200.
Contract amount*
Please enter a number greater than or equal to 50.
Date Offset
Date Format: DD slash MM slash YYYY
Min Offset
Date Format: DD slash MM slash YYYY
Monthly debit order date starting from*
Date Format: DD slash MM slash YYYY
and thereafter regularly on the:
Monthly debit order day*
Monthly debit order day*
Please debit my account within 72 hours of signing this mandate and thereafter on debit date selected*
- Yes
- No
Instant EFT
- I also wish to pay an instant EFT amount
Instant EFT Amount*
Terms of agreement
I hereby authorise you to issue and deliver payment instructions to your banker for collection against my above mentioned account at my above mentioned bank (or any other bank or branch to which I may transfer my account) on condition that the sum of such payment instructions will never exceed my obligations as agreed to in the donation agreement and commencing on the payment date as selected above and continuing until this authority and mandate is terminated by me by giving you notice in writing of not less than 20 ordinary working days, and sent by email. I understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks and I also understand that the details of each withdrawal will be printed on my bank statement. I understand that my bank will apply charges at their ruling rates for unmet transactions. I also understand that any banking fees incurred by GREENPEACE Africa may be recovered of unmet transactions. If the payment day falls on a Sunday or recognised South African public holiday, the payment will automatically be processed the previous ordinary business day. I authorise the originator to make use of the tracking facility as provided for in the EDO system at no additional cost to myself. ASSIGNMENT I 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. CANCELLATION I agree that although this Authority and Mandate may be cancelled by me, I shall not be entitled to any refunds of amounts which you have withdrawn while this authority was in force if such amounts were legally owing to you. I understand that cancellations may only take effect a month later.
Terms of agreement
I hereby authorise you to issue and deliver payment instructions to your banker for collection against my above mentioned account at my above mentioned bank (or any other bank or branch to which I may transfer my account) on condition that the sum of such payment instructions will never exceed my obligations as agreed to in the donation agreement and commencing on the payment date as selected above and continuing until this authority and mandate is terminated by me by giving you notice in writing of not less than 20 ordinary working days, and sent by email. I understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks and I also understand that the details of each withdrawal will be printed on my bank statement. I understand that my bank will apply charges at their ruling rates for unmet transactions. I also understand that any banking fees incurred by GREENPEACE Africa may be recovered of unmet transactions. If the payment day falls on a Sunday or recognised South African public holiday, the payment will automatically be processed the previous ordinary business day. I authorise the originator to make use of the tracking facility as provided for in the EDO system at no additional cost to myself. ASSIGNMENT I 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. CANCELLATION I agree that although this Authority and Mandate may be cancelled by me, I shall not be entitled to any refunds of amounts which you have withdrawn while this authority was in force if such amounts were legally owing to you. I understand that cancellations may only take effect a month later.
Signature*
Signature verified by Bank
Source

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