DEBIT ORDER MANDATE

Please help us to plan effectively : We can only plan future distributions of shoes if we have sufficient funds. By donating per debit order, you are helping us to plan more effectively.

The reference number on the bank statement will always start with MULTID FOR SFEET plus your unique reference number.
Name & Surname *
Name & Surname
Telephone Number *
Telephone Number
Physical Address
Physical Address
Debit Order Authorisation
I wish to make a monthly contribution towards SAMARITAN’s FEET SA. I therefore request and authorise you to debit my account at the bank mentioned below (or other bank or branch to which I may transfer my account) with
R
Scheduled Debit Order Date
The first deduction is to take place on
I also authorise you to debit my account with once off amounts from time to time as and when intructed by me per email/in writing
The details of my bank account are as follow:
Type of account *
Declaration
I understand that the deductions hereby authorised will be processed by means of a system known as Sanlam Multi Data Services, and I understand that the details of each deduction will be reflected on my bank statement and on an accompanying printed slip, with the reference MULTID FOR SF with my unique number. I also understand that I have to quote this reference in my communication with Samaritan’s Feet. I agree to pay any bank charges relating to this debit order. This authorisation may be cancelled by me by giving you 30 (thirty) days written notice. I understand, however that I am not entitled to a refund of amounts deducted by you while this authorisation is valid. The receipt of this instruction by you is considered tantamount to my bank acknowledging receipt thereof.
Date *
Date
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