(LS) #** CW001 – JOBURG CHILD WELFARE Electronic debit order mandate for a once-off or monthly donation to Joburg Child Welfare Email address* Enter email address Confirm email address Authority given by:First name*Surname*Date of birth* Date Format: DD slash MM slash YYYY Town/city of residence*Cell no.*Payment Method*Bank AccountCredit CardBank 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 BANKFINBOND MUTUAL BANKACCESS BANKBANK OF CHINABANK ZEROBNP PARIBAS SA SOUTH AFRICACHINA CONSTRUCTION BANKFINBOND NET1ICICI BANK LIMITEDJ.P.MORGAN CHASE BANK N.ASOCIETE GENERALEBranch code*Account number*Type of account*Current (Cheque)SavingsTransmissionCredit card details:Credit Card* MasterCardVisa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Agreement:Abbreviated short name as registered with the acquiring bank: CHILD WELFReference*Your reference number will be generated on submission.I want to donate*MonthlyAnuallyOnce-offContract Amount*Annual escallation Please increase my donation by 10% every year. MandateI/We hereby authorise CHILD WELF 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* Date Format: DD slash MM slash YYYY 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 Joburg Child Welfare, P O Box 62606, Marshalltown, 2107. 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 Joburg Child Welfare work. Signature*Signature verified by Bank