hereby authorise you to debit my account on a monthly basis with the sum of:
Please Select
R180
R360
R540
R720
R900
R1080
R1260
R1440
R1620
R1800
Name
*
Email
*
Cell Phone
*
Format: (000) 000-0000.
Tax Number
ID Number
*
Address
Postal Address
*
Residential Address
*
Physical address is the same as the postal
Banking Details
Account Name
*
Bank Name
*
Branch Name
*
Account Number
*
Branch Code
*
Account Type
*
Please debit my account on the
8th
18th
28th
*
of each month
Type of Monthly Payment
*
Type of Monthly Payment
New Monthly Donation – My Fair Lady
Signature
Date
*
-
Day
-
Month
Year
Date Picker Icon
Submit
Should be Empty: