Name of Scheme: Afri Vroue Fonds (AFV) Monthly Donation

Donor Information

Title
MrMrsMs

Surname

Full Names

ID Number

Mobile Number

Town/City

Province
—Please choose an option—Eastern CapeFree StateGautengKwaZulu- NatalLimpopoMpumalangaNorthern CapeNorth WestWestern Cape

Email Address

DEBIT ORDER AUTHORISATION

Bank Name

Branch Code

Account Holder - (Whose name is the account in?)
If not in your name, please provide the Account Holder’s contact number (for verification)

Account Number

Account Type
ChequeSavingsTransmission

Reference
—Please choose an option—Dedicated Housing FacilitiesMonthly Tea PartiesStudie AidSupport Women in Need

Amount

First Debit Date
1ste5de10de15de20ste25steLast day of the month

Frequency
MonthlyOnce-OffAnnually

Please note that your authorization and mandate will be confirmed via recording before any debit order is processed against your account. You hereby authorize Phakama to debit your account on behalf of Virtucall (Pty) Ltd, which represents Afri Vroue Fonds. Your debit order will be processed on the requested date. Should the debit order fail for any reason, a second attempt will be made in the following month. The mandate will be cancelled if the second attempt is also unsuccessful. If your debit date falls on a Sunday or a recognized public holiday, the debit will be processed on the next working day. You may cancel this mandate by providing 30 days’ written notice, though this will not immediately cancel this agreement. You will not be entitled to a refund of any funds collected while this authority is in effect. This agreement can only be assigned to a third party if the mandate is transferred along with it. You acknowledge and agree that this instruction to debit your account will be recognized as a payment instruction given by you. Your bank statement will reflect the transaction as: AFRF. Do you understand this mandate? Please confirm below before submitting the form.