(LS) #62 CAM001 – CAMPAIGN-CO CAMPAIGN-CO Electronic debit mandate Campaign*Authority given by:Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Contact Number*Email Address* Enter Email Verify Email ProvinceEastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorth WestNorthern CapeWestern CapeI want to donate*WeeklyOnce-offWeekly Contribution*R12 per weekR20 per weekR25 per weekR50 per week*debited once monthly at R52, R86, R108 or R216 respectfully).Please consider an easy to manage weekly contribution above.Once-off Contribution*R50R100R250R500R800R1200R2500Payment 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 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*Type of account*Current (Cheque)SavingsTransmissionCredit card details:Credit Card* MasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Agreement:Abbreviated short name as registered with the acquiring bank: CAMPAIGNCORefer to our donation reference number (“the Donation Reference Number”):Campaign Reference*Start date for first debit to my account* Date Format: DD slash MM slash YYYY and thereafter regularly on the:Monthly debit order day*1st15th20th25thTerms 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 CAMPAIGNCO 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 This iframe contains the logic required to handle Ajax powered Gravity Forms.