Please print the form and mail it after completion to Radio Pulpit at P.O. Box 3436, Pretoria, 0001 OR fax: (012) 334-1400.

RADIO PULPIT DEBIT ORDER
FROM:
Name: .....................................................................................................
         TITLE, INITIALS AND SURNAME
Postal Address: ................................................................................................................

                .......................................................................................................................

                .......................................................................................................................

                ...................................................................... Postal code: ..............................
Tel (W): .................................................... (H): ......................................................

      (C): ...................................................(E-mail): .................................................

  
ID No:  
MY AGREEMENT FOR REGULAR FINANCIAL SUPPORT  
PLEASE MARK WHERE APPLICABLE:  
   
This is my first Radio Pulpit debit order authorisation This replaces my existing debit order authorisation
MY BANK DETAILS ARE RECORDED BELOW:
INDICATE THE TYPE OF ACCOUNT: Cheque      Transmission      Savings      Credit Card
Name of account holder: ........................................................................................................
Name of bank: ........................................... Branch name: .....................................................
Account Number: ............................................. Branch code: ................................................
Amount: R ................................. in words: ............................................................................
I hereby request that you debit my account at the above-mentioned bank (or any other bank or branch to which I may transfer my account) monthly/annually as from ............................. 20............... All such withdrawals you make from my account shall be treated as though they were signed by me personally.

I understand that the withdrawal(s) hereby authorised, will be processed by computer and that all the details of each withdrawal will be printed on my bank statement. I will pay any bank charges relating to this debit order authorisation.

This authorisation may be cancelled by me in writing. I understand that I shall not be entitled to any refund of amounts which Radio Pulpit has withdrawn while this authorisation was in force.

 

_____________________________                                                           _________________________
SIGNATURE OF ACCOUNT HOLDER                                                             DATE