Debit Order Form - LookGoodFeelBetterSA : Helping Women With Cancer Feel Better

Please support us with a monthly debit order contribution by completing and submitting the below Debit Order Authorization form:

LGFB Debit Order Authorisation Form

First Name *

First Name

Last Name *

Last Name

Your Address *

Your Address

Your ID Number *

Your ID Number (required):

Contract No *

Contract No

Email: *

Email:

Debit Amount *

Debit Amount (required):

Debit Order Commencing Date

Payment Day of each and every month : i.e. 1st, 15th,25th or 31st Day Of The Month *

Payment Frequency

Message:

Dear Sirs/Madams The details of my/our account are as follows:

Bank Name (required): *

Bank Name (required):

Branch No.: *

Branch No.:

Account Holder Name: *

Account Holder Name:

Bank Account Number (required): *

Bank Account Number (required):

Account Type (required): *

Account Type (required):

This signed Authority and Mandate refers to our contract as dated as on signature hereof ("the Agreement"). I / We hereby authorise you to issue and deliver payment instructions to the bank for collection against my / our abovementioned account at my / our above mentioned bank (or any other bank or branch to which I / We may transfer my / our account) on condition that the sum of such payment instructions will never exceed my / our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me / us by giving you notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above. The individual payment instructions so authorised to be issued must be issued and delivered as follows: I. On the “Payment Day"(as stated above) of each and every month on the Debit Order Commencing Day (as stated above). In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account; Monthly; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due selected *

I Agree

Please tick the box to agree to this Authority & Mandate

Print Your Name (required) *

Print Your Name (required)