Name & Surname *

Address *

Mobile Number *

Alternative Contact Number

Email Address *

Monthly Debit Amount *

I confirm commencement date of monthly debit as 3rd of each month, commencing on (insert date and month) *

Bank *

Account Name *

Branch Name *

Branch code *

Account Type *

Account Number *

Would you like a Section 18A Tax Certificate? *

I/we hereby instruct and authorise the appointed service provider (on behalf of THE CHAELI CAMPAIGN) to draw against my/our account with the set amount, which is due and payable by me/us in terms of this agreement for the service I/we have selected. This order will remain effective until cancelled by me in writing. I/we may choose to cancel this debit order instruction at any time in writing giving 30 days notice. If cancellation is not implemented before the 15th of the month, the debit order will continue for the next month. I/we understand that there are bank charges associated with this debit order as with all debit orders. *

Date *