(DD) #83 SGA001 – SimpletoGive (CARLSTRONG) Electronic debit order mandate. Thank you for supporting the AEC 180 campaign and helping to provide quality education to learners from the Alexandra township.Donor Type*Individual (R250)Individual (R180)Individual (R100)Business (R900)Corporate (R1800)Beneficiary*AEC (Alexandra Education Committee NPO No. 025-968)WAIVE Services (WAIVE RESEARCH PTY Ltd.)CARLSTRONG (Carlstrong Foundation NPO No. 209-743)ODU (Old Dalian Union)THE GOOD FIGHT (Guinness World Records for Charity)THE LETTIE LOVE FUND (NPO No. 243-135)Authority given by:Company Name*Registration NumberOptional for tax certificateVAT NumberOptional for tax certificateTax Certificate Please tick here to confirm if you wish to receive a Tax Certificate Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Person signing on behalf of entity*Anonymous Donation? Make this an anonymous donation (Name will not appear on donor board) Address Postal Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email Address* Contact Number*ID TypeRSA IDOtherID NumberOther IDDate of Birth* Date Format: MM slash DD slash YYYY Bank account details:Account Holder*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*Account Type*Current (Cheque)SavingsTransmissionAgreement:Reference*How long do you want to donate?*Indefinite12 MonthsContract Amount Type*StandardCustomContract Amount*Contract Amount*I/we agree that the first payment instruction will be issued and delivered on:Start Date* Date Format: DD slash MM slash YYYY and thereafter regularly on the:Debit day*1stNewsletter subscription Please tick here to confirm you wish to receive communication from us. Terms of agreementAbbreviated short name as registered with the acquiring bank: WAIVE Refer to our contract reference number (“the Contract Reference Number”). I/We hereby authorise WAIVE RESEARCH (PTY) LTD. to collect funds on behalf of selected “Beneficiary” above and 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 the "Start Date" and thereafter regularly on the "Action Day" of each month. If however, the date of the payment instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction 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 canceled 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 or delivered to your address indicated above. 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.Signature*Signature verified by BankSource This iframe contains the logic required to handle Ajax powered Gravity Forms.