Debit Order Authorisation Agreement
Name (Donor) : __________________________
1st Payment Date:
________________
Address :
__________________________
Last Payment Date:
________________
__________________________
Monthly Payment Date: ________________
__________________________
Recurring Debit Amount: ________________
Email:
__________________________
Tel Number:
__________________________
Dear Sirs/Madams,
The details of my/our account are as follows:
BANK:
________________________
BRANCH TOWN:
__________________________
BRANCH NO. : ________________________
ACCOUNT NAME. : _________________________
ACCOUNT NO. : ________________________
TYPE OF A/C:
1.
2.
3.
4.
5.
6.
_________________________
I/We, the authorised signatory/ies, warrant that I/we are duly authorised to sign this Debit Order Authorisation
Agreement and by my/our signature hereto, confirm that I/we shall have no claims against Colors Foundation NPC and/or
its nominated representative and/or agent arising out of this Debit Order Authorisation Agreement.
I/we hereby request, authorise and “instruct” Colors Foundation NPC (or its nominated representative and/or agent) to
draw against my/our account with the abovementioned bank (or any other bank or branch to which I/We may transfer
my/our account) the Recurring Debit Amount monthly, on the date(s) stipulated above.
All such withdrawals from my/our account by Colors Foundation NPC (or its nominated representative and/or agent) shall
be treated as though they had been signed by me/us personally. We undertake to ensure that adequate funds are
available in the bank account detailed in this agreement, to cover the amounts due in terms of this Debit Order
Authorisation Agreement.
I/We understand that in the event that any debit order due in terms of this Debit Order Authorisation Agreement is
rejected by my/our bank, all related bank rejection fees will be due and payable immediately by me/us.
I/We undertake to inform Colors Foundation NPC of any changes to my/our bank account details listed in the Debit Order
Authorisation Agreement. I/we understand that if bank details have been supplied the withdrawals authorised here will be
processed by the nominated representative and/or agent of Colors Foundation NPC. I/we also understand that details of
each withdrawal will be printed on my/our statement. I/we agree to pay any banking charges relating to this debit order
instruction. This authority may be cancelled by me/us by giving Colors Foundation NPC thirty days written notice.
I/We acknowledge that the party hereby authorised to effect the drawing(s) against my/our account may not cede or
assign any of its rights and that I/we may not delegate any of my/our obligations in terms of this authority to any third
party without prior written consent of the party hereby authorised to effect the drawing(s) against my/our account.
Full name and signature on behalf of Donor duly authorised thereto:
Signed at _____________________ on this ________ day of _________________ 2013
Signature ____________________________ Print Name ____________________________
Donation Pledge
(AmazingBrainz Copy)
Name (Donor) : __________________________
1st Payment Date:
________________
Address :
__________________________
Last Payment Date:
________________
__________________________
Monthly Amount:
________________
__________________________
Email:
__________________________
Tel Number:
__________________________
Dear Sirs/Madams,
I/We hereby pledge to donate the above amount/s to Colors Foundation (pending a name-change to
AmazingBrainz).
Signed at _____________________ on this ________ day of _________________ 2013
Signature ____________________________ Print Name ____________________________
Cut here
Donation Pledge
(Donor Copy)
I/We have pledged to donate the following amount/s to Colors Foundation (pending a name-change to
AmazingBrainz):
1st Payment Date:
________________
Last Payment Date:
________________
Monthly Amount:
________________
BANK DETAILS
Account Name:
Bank:
Account Type:
Account Number:
Branch:
Swift:
CONTACT DETAILS
Colors Foundation
Standard Bank
Cheque
27 256 4613
050210
SBZAZAJJ
Tel: (+27) (0)21 807 5000
Fax: (+27) (0)21 807 5001
E-mail: info@amazingbrainz.org
Web: www.amazingbrainz.org