DEBIT ORDER AUTHORITY

Please print this page, fill in the form and mail the original to us!

To
The Manager
Brotherhood of Blessed Gérard
PO Box 440
4490 Mandeni

From: _____________________________________

Postal Address

__________________________________________


_____________________________Code_________


Telephone:	__________________________Home

		__________________________Work

Dear Sir

The details of my account are as follows:

Type of account: Cheque (Current) ___ Savings account ___ Transmission account ____

Name of account holder:

 

Name of Bank:

  Branch  

Account number:

  Branch code  

Amount:

R

Amount in words 

I hereby request and authorise you to draw against my indicated account with the above mentioned bank (or any other bank or branch to which I may transfer my account) the above mentioned amount on the ____________ day of each and every month commencing on ______________. All such withdrawals from my bank account by you shall be treated as though they had been signed by me personally. Should this debit order not reach the Brotherhood of Blessed Gérard in time for processing on the above mentioned date, I hereby authorise the Brotherhood of Blessed Gérard to collect outstanding payments in the following month in which the debit order comes into operation.

This authority may be cancelled by me giving the Brotherhood of Blessed Gérard 30 (thirty) days notice in writing, sent by prepaid registered post.


________________________
_________________

Signature of account holder

Date

We thank you wholeheartedly for your valued support!



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Page last updated on Tuesday, 22 April 2008 01:26:07