Debit order

Loaves and Fishes Network - Online Debit Order Application Form

Help the Loaves and Fishes Network (LAFN) ensure a reliable and predictable income throughout the year by authorising LAFN to draw a small amount from your bank account per month.
The Loaves and Fishes Network aims to assist as many children as possible affected by PVA (poverty, violence and Aids) in and around Buffalo City. It is a network joining the hands of government, civil society and private business with those of PVA-affected children.
“We need to elevate all children to the entitlement of a full, stimulated, normal childhood. It's a birth right, and if their parents fail, we as a community must step in." - Dr Trudy Thomas, Chairperson

I/We hereby request, instruct and authorise Three Peaks / LAFN to draw against my/our below-mentioned bank account (or any bank/branch where I/we may transfer my/our account) the amount necessary for the monthly payment due in respect of the below mentioned agreement as follows:
Day of each month to effect deduction: /

Amount to Deduct (please check):

 R25 R35 R50 R100 R200
Other amount

Personal Details:

Title

First Names

Surname

Postal Address

Postal Code

Banking Details:

Name of Bank

Account Number

Branch

Type of Account (please check):
 Savings Transmission Cheque

Contact Details:

Language

Contact Numbers:

Home

Work

Cell

*Email Address

TERMS AND CONDITIONS

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 to any third party without my/our prior written consent and that I/we may not delegate any of my/our obligations in terms of this contract/authority to any third party without prior written consent of the authorised party.
All such withdrawals from my/our bank account by you shall be treated as though they had been signed by me/us personally.
I/we agree to pay the bank charges relating to this order instruction.
This authority may be cancelled by me/us by giving thirty days written notice and will not hold LAFN liable for refund of any debit order amount that may have been drawn while this authority was in force.

I accept the terms & conditions.