My Gift is a: |
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Amount: |
R 20
R 50
R 100
R 500
Other
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First Name: |
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Middle Initial: |
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Last Name: |
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Address 1: |
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Address 2: |
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City: |
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State: |
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Zip Code: |
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Phone: |
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E-mail Address: |
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| My
preferred payment method: |
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CASH/Cheque
Direct Internet Transfer
Debit order |
Banking details for Cash/Cheque
payments or EFT: |
AGS
Scottburgh |
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Standardbank Rek No: 052850889 ; |
Bankcode:
05-76-27; Scottburgh ; |
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| Please specify your gift type: |
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This is a one time gift.
Please initiate a monthly debit order until
I notify you to stop. |
Here
follows my details: |
BANK: |
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Bank
Code: |
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Account #: |
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Date of debit order: |
Today
on the 1st of the month
on the 30th of the month |
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