DEBIT ORDER AUTHORITY

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

To
The Manager
Blessed Gérard's Care Centre
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 Blessed Gérard's Care Centre in time for processing on the above mentioned date, I hereby authorise Blessed Gérard's Care Centre to collect outstanding payments in the following month in which the debit order comes into operation.

This authority may be cancelled by me giving Blessed Gérard's Care Centre 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, 15 January 2013 12:50:11