E-Mandate

Electronic debit order mandates for your business.

(LS) #37 BLA001 – Breadline Africa

Electronic debit order mandate

OTP Verification
Fundraiser Name
Fundraiser ID
Location
Location
Authority given by:
Name*
First Last
Occupation*
ID Type*
- RSA ID
- Other
ID Number*
Other ID*
Date of Birth*
Date Format: DD slash MM slash YYYY
Landline Number
Cellphone Number*
Email Address*
Find address using Google Maps
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you over 25 years old?*
- Yes
- No
We unfortunately do not accept donations from anyone under 25 years of age.
Are you employed?*
- Yes
- No
Do you have another source of income?*
- Yes
- No
We unfortunately do not accept donations from anyone who is unemployed and does not have an additional source of income.
Is your household income R7000 or more per month?*
- Yes
- No
We unfortunately do not accept donations from anyone whose household income is less than R7000 per month.
Payment Method
Bank account details:
Bank*
Branch code*
Account number*
Type of account*
Credit card details:
Credit Card*

MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Agreement:
Abbreviated short name as registered with the acquiring bank: BREADLINE
Refer to our contract reference number (“the Contract Reference Number”):
Reference*
I want to donate*
- Monthly
- Once-off
Contract amount*
Please enter a number greater than or equal to 150.
Contract amount*
Please enter a number greater than or equal to 150.
I confirm this is a monthly debit order commitment*
- Yes
- No
Monthly debit order date starting from*
Date Format: DD slash MM slash YYYY
Account to be debited last working day of each month*
- Yes
- No
Only select yes if you wish debit to be processed on the last working day of each month, if any other date select no.
and thereafter regularly on the:
Monthly debit order day*
Beneficiary’s address: Breadline Africa (RSA) 1 Platinum Park, 101 Capricorn Drive, Capricorn Business Park, Muizenberg, Cape Town, 7945
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 Breadline Africa (RSA) may be recovered of unmet transactions.
If the payment day falls on a Saturday, Sunday or recognised South African public holiday, the payment will automatically be processed the next ordinary business day.
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.
Keeping you informed is important to BREADLINE AFRICA (RSA). We like to let our supporters know what their donations are helping to achieve for children, by sharing news of our work.
Newsletter Subscription
- Please tick here to confirm you wish to receive communication from BREADLINE (RSA).
Signature*
Signature verified by Bank

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DISCONNECTED: CHECK INTERNET CONNECTION

Authority given by:

Bank account details:

Credit card details:

Agreement:

ASSIGNMENT

CANCELLATION