(LS) #66 COP001 – COPE Electronic debit order agreement Province*Eastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorth WestNorthern CapeWestern CapeAuthority given by:Name* First Last Gender*MaleFemaleID Number*Residential Address* Street Address Address Line 2 City Postal Code Telephone Number*Cell Number*Email Address* Date of Birth* Marital Status*SingleMarriedDivorcedWidowedOtherNumber of Dependents*012345678910RaceBlackColouredIndianWhiteOtherFor statistical reasons onlyHome Language*AfrikaansEnglishKoi SanNdebeleNorthern SothoSothoSiswatiTsongaTswanaVendaXhosaZuluOtherReligionChristianIslamHinduismAfrican TraditionJudaismNo ReligionOtherFor statistical reasons onlyHighest Education LevelGrade 10 or LowerBasic Adult EducationMatricDiplomaDegreeHonoursMastersDoctorateProfessorOtherFor statistical reasons onlyEmployment TypePermanentContractTempRetiredUnemployedFor statistical reasons onlyOccupationFor statistical reasons onlyWard Number*Find your ward number here.Membership fees:Membership Fees Paid for*1 Year2 Years3 Years4 Years5 YearsMembership* COPE Membership (R30/year) COPE WM COPE YM COPE SM COPE B&P Total Membership for:*Contract amountHow would you like to pay for your membership?*Bank AccountCredit CardCash / EFTManual Historic PaymentBank 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 CVV Number Cardholder Name Manual historic payment:Deposit Date* Deposit Amount*Deposit Reference Number*Agreement:Abbreviated short name as registered with the acquiring bank: COPERefer to our contract reference number (“the Contract Reference Number”):Reference*Annual debit date* I confirm I subscribe to* COPE Constitution COPE Policies Code of Conduct Membership declaration*I SOLEMNLY DECLARE THAT, FROM THE TIME I AM RECOGNISED AS A BONA FIDE MEMBER OF THE CONGRESS OF THE PEOPLE (COPE), AND TO THAT EFFECT ACCEPT MY MEMBERSHIP CARD, AND FOR AS LONG AS REMAIN A MEMBER;1. I SHALL BE A PATRIOTIC SOUTH AFRICAN, and accordingly discharge my responsibility to protect, and defend the Constitution of the Republic of South Africa, to exercise my right and responsibility to vote at all times, and mobilise other South Africans to do the same, and to defend our hard won freedom by contributing to building a prosperous country for all.2. I SHALL ABIDE BY, AND BE LOYAL TO, THE CONSTITUTION OF THE CONGRESS OF THE PEOPLE, a party with its historic roots in the congress movement of our country whose vision for South Africa, the Freedom Charter , was adopted at the Congress of the People in Kliptown in 1955;3. I SHALL MOBILSE SOUTH AFRICANS TO JOIN, SUPPORT AND/OR VOTE FOR THE CONGRESS OF THE PEOPLE and contribute to making it the natural political home for all South Africans committed to building a country of prosperity for all, in which all citizens are, and feel, protected to exercise their rights and responsibilities without fear or favour, as well as avail myself to serve the Party where I feel competent and ready while respecting the decision of the Party on that as final;4. I SHALL RESPECT THE PARTY AND SOCIETAL VALUES seeking at all times to align, through my conduct and pronouncements, the broader societal values with those of the Party, respect and protect all the Party and national symbols as well as the oath of public office;5. I SHALL TREAT ALL PARTY MEETINGS, CONFERENCES AND CONGRESSES WITH UTMOST RESPECT, GUARD THEIR INTEGRITY AND UPHOLD THEIR DIGNITY, recognising their critical role as centres of entrenching a solid culture of participatory, accountable and democratic governance in the Party and therefore society, will prepare myself to contribute effectively in the meetings to ensure their successful conclusion, and will not, unless so officially authorised, divulge the content or any aspect of what takes place in them to any third party, gathering, the media, social media or any form of electronic or other public communication means, failing which such conduct shall be a serious misconduct and be subject to the Party’s disciplinary processes;6. I SHALL RESPECT AND ABIDE BY THE DECISIONS OF THE PARTY and not denounce such decisions or attack the character or person of, or disrespect in any way, any leader or member of the Party, to or through any third party, gathering, the media, social media or any form of electronic or other public communication means, or act in any way that may bring confusion in the minds of the members of the Party or public or saw division or factionalism in the ranks of the Party;7. I SHALL CONTRIBUTE TO ENSURING FREE AND FAIR ELECTIONS IN THE PARTY and country, respect the leadership elected, and if not satisfied and believe that the results of the elections may be, or have been, compromised in any way, I will use proper channels and procedures agreed to respect the final outcomes of such processes, procedures or structures;8. I SHALL ABIDE BY THE PARTY CODE OF CONDUCT, DISCIPLINARY POLICY AND PROCESSES and shall not do anything that may bring the name of the Party or the country into disrepute or behave in a manner that is in any way divisive, factional or amounts to the abuse of power;9. I SHALL AT ALL TIMES CONDUCT MYSELF IN A MANNER THAT INSPIRES HOPE as well as represents and carries the aspirations of all the people of South Africa in their diversity;10. I SHALL CONTRIBUTE TO ENSURING THAT OUR PARTY AND COUNTRY play their respective roles as forces for progressive change and stability for a better Africa and humane world based on a human rights culture that respects the equality of peoples and nations in principle and in practice. I have read, understood and agree to abide by the Membership Declaration set out above. 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 the Congress of the People 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.