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DEBIT ORDER FORM

I, the undersigned, herewith authorize Al-Azhar Institute of Cape Town to arrange with my banking institution for the amount to be drawn against my account in accordance with the debit order system.

SURNAME:………………………………………………………………..……………TITLE:…………………..

FIRST NAME:………………….…………………………………………………………………………………...

ADDRESS:……………………………..……………………………………………………………………………

………………………………………..…………………………………………………CODE:.…………………..

AMOUNT:…………………………………………………........................................................................

DEDUCTION DATE:………………………………………......................................................................

NAME OF BANK:…………………………………………………………..................................................

BRANCH:……………………………………………………....................................................................

BRANCH CODE:……………………………………......................................................................... ACCOUNT NO:………………………………………………………………………………………..................

TYPE OF ACCOUNT:

O CHEQUE

O SAVINGS

O TRANSMISSION

TEL:(W)…………………………………………..……   (H)……………………………..………………..........   MOBILE:………………………..………………........

I acknowledge that the party hereby authorized to affect the drawing(s) against my account may not cede or assign any of its rights to any third party without any prior written consent, and that I may not delegate any of my obligations in terms of this contract/authority to any third party without prior written consent of the authorized party.

SIGNATURE:…………………………………………………………………………………............................             DATE:…………………………………………………….

(THIS AGREEMENT WILL REMAIN VALID UNTIL IT IS RECALLED IN WRITING BY EITHER OF THE PARTIES.)

Al-Azhar Institute of Cape Town, 20 Cashel Avenue, Athlone, 7764, Western Cape, South Africa

Banking Details:

Bank: Standard Bank

Name of Account: Al-Azhar Institute of Cape Town

Branch: Vangate Mall

Branch Code: 025909

Account No: 073316016