Debit Order

First Name*
Last Name*
Contact Number*
Email Address*
Physical Address*
Street Address Address Line 2 City Province Postal Code Country
Donation Amount*
Type*
Debit Order Mandate
Debit Order Day*
Name of Bank*
Branch Name*
Account Holder*
Account Type*
Account Number*
Branch Code*
I instruct and authorise THE RIVERS FOUNDATION to draw from the above amount from the my account EACH MONTH.

All withdrawals will be treated as though they have been signed by me.
Signature*
Date*
Date Format: DD slash MM slash YYYY
Credit Payment are facilitated by PayFast. You will be redirected there to finalise your donation.

Debit Order Mandate