Girls and Boys Town Integrated Biennial Report April 2018 – March 2020

Girls & Boys Town South Africa Integrated Biennial Report 2018/2020 57 GIFT BY DEBIT ORDER Name of contributor Contact person Title Initials Surname Telephone No Work Home Cell Fax No Email ID number Postal address Code Physical address Code Occupation of contributor Debit order details First contribution due on the 2nd or 23rd (circle the applicable day of 20 and each month thereafter until cancelled by me in writing Contribution Amount in words Bank Branch name and town Branch number Account number Account type Name in which account is held I/We authorise Girls & Boys South Africa to debit the amount of the gift specified above against my/our bank account as indicated. Girls & Boys Town South Africa is legally entitled to the amount withdrawn in terms of this authority from my/our bank account while this authority is in force and until I have notify you at your address in writing of the cancellation of this authority. Signed at on this day of 20 Signature Seconded signature for joint accounts For office use only Please circle the applicable allocation (1) New Increased Re-instated Fundraiser’s name Cut out and return to GBT office or email to fundraising: mailing @gbtown.org.za ✂ is for Significance is for Home is for Independence is for Nurturing is for Education