(LS) #** SLH001 – STLUKES Electronic debit mandate Type of accountIndividualBusinessAuthority given by:Name* First Last ID Type*RSA IDOtherID Number*Other ID*Company Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address* Contact Number*Donation / ApplicationDonation / Application Type*Club 2000Corporate sponsor a lightBuy a light in memory of someone specialR100,000 drawDonationClub 2000 Type*Club 2000Club 2002Club 2003Club 2000*R50 for 1 lucky numberR100 for 2 lucky numbersR150 for 3 lucky numbersR200 for 4 lucky numbersClub 2002*R50 for 1 lucky numberR100 for 2 lucky numbersR150 for 3 lucky numbersR200 for 4 lucky numbersClub 2003*R50 for 1 lucky numberR100 for 2 lucky numbersR150 for 3 lucky numbersR200 for 4 lucky numbersCorporate sponsor a light*R1000 for Corporate single lightR5000 for Corporate BranchR10 000 for Corporate StarBuy a light in memory of someone special*R150 for single lightR300 for double lightR1000 for family branchR2000 for family starR100,000 draw*R200 per ticket x __ no of ticketsR100,000 draw amount*Donation*Once-offMonthly debit orderAnnual debit orderDonation Amount*Payment MethodBank AccountCredit CardBank account details: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 BANKINGCAPITEC BUSINESS BANKMTN 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 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name Agreement:Abbreviated short name as registered with the acquiring bank: STLUKESRefer to our donation reference number (“the Donation Reference Number”):Abbreviated short name as registered with the acquiring bank: CLUB2000Refer to our donation reference number (“the Donation Reference Number”):Reference*Contract Amount*Monthly debit order date starting from* Date Format: DD slash MM slash YYYY Terms of agreementI 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 ST LUKE'S 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 next 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
