<p> 2 Wynne Row The Addiction Action Campaign 50 Johannes Street Fairland Sobriety & Success 2195 - Gauteng</p><p>Web : http://www.aac.org.za Tel +27 (0)790663382 E-mail : [email protected] NGO Registration | NPO 064-990 Fax +27 (0)866467953</p><p>BANK DEBIT ORDER DONATION INSTRUCTION </p><p>I/we hereby authorize you to debit my/our account from the banking details mentioned below (or any other bank or branch that I/we may change to) the sum of ______which relates to a monthly debit donation which I would like to make to your organisation. Please debit me on the ______working day of each month. This sum being will run concurrently until further notice or, I would like the final debit of the same amount to take place on (DD/MM/YYYY) Or I/we hereby authorize you to debit my/our account with a once off amount of ______which relates to a once off debit donation which I would like to make to your organisation. Please debit this amount from my account on (DD/MM/YYYY) </p><p>I/we hereby authorize your agent MyGate Communications (Pty) Ltd to debit my/our account on your behalf. </p><p>This debit order agreement may be cancelled by giving thirty days written notice in writing but I/we understand that any amounts withdrawn while this agreement was in force can’t be refunded as they may have used for the purposes for which they were intended by me.</p><p>I/we hereby agree that the party hereby authorized to debit my bank account may not cede or assign any of its rights and that I/we may not cede any of our obligations in terms of this debit order instruction to any third party without prior written consent of the authorized party.</p><p>Name: Date: Address: Contact Number: </p><p>Donor Bank Account Details</p><p>Account Name: Bank: Account Number: Branch Number: Account Type: Company reg. or ID number: </p><p>Signature: Fax this form to 086-646-7953 </p><p>For cash or EFT donations The AAC’s current banking account is Nedbank, Chapel Street Kimberley Account number: 1035383071 - Branch Code: 103502 Account name: The Addiction Action Campaign | Please add deposit reference : Donation </p><p>Directors: Mr WH Whitfield (Chairman), Mr TJ Casey, Mr NH Ofsowitz, Mr DJ Rees, Mr WM Rogers, Miss N Schoeman, Mr SM Hooks</p>