Pif Bursary Pledge Form

Gift form My relationship to Wits: Alumnus

Student

Parent

Friend of Wits

Name: .......................................................................................................... Postal address: ........................................................................................... ....................................................................... Postal code: ........................ Country: ....................................................................................................... Contact telephone number: ........................................................................ Fax number: ................................................................................................ E-mail: ......................................................................................................... Cellphone: ...................................................................................................

I enclose my gift to the Chancellor’s Annual Fund R ............................ Are you interested in supporting a specific project or faculty or may we allocate the donation for you? Please indicate below: ......................................................................................................................

"Pay it Forward Bursary" ...................................................................................................................... My cheque (made payable to The Wits Foundation) is enclosed I have made my gift online at www.fundraising.wits.ac.za I have completed my details overleaf for a gift via credit card/direct deposit Please send me more information about making a bequest to Wits Official website address: www.fundraising.wits.ac.za • Telephone number: (011) 717-9703 • Fax number: (011) 717-9729 Queries: Contact the Development & Fundraising Office • E-mail address: [email protected] 9051

Gift options Credit Card Please debit my MasterCard/Visa Card (Last 3 digits on reverse of card)

Card no.:

Expiry Date:

M M Y Y

in the amount of: ......................

Once only

Every month

Tel. No.: (............) ............................................................................................ Signature: .............................................................. Date: ............................... I/we acknowledge that the party hereby authorised to effect the drawing(s) against my/our account may not cede or assign any of its rights to any third party without my/our prior written consent and that I/we may not delegate any of my/our obligations in terms of this contract/authority to any third party without prior written consent of the authorised party. Thank you for your co-operation.

Internet Bank Transfer or Direct Deposit I have deposited my donation into your bank account. Bank: Standard Bank of South Africa Limited Account Name: Wits Foundation Number Two Account Account Number: 00 290 0076 Branch Code: 00 48 05 Swift Code: SB - ZAZ - AJJ - 480502 *Please be sure to include your full name as the reference, so we may thank you for your gift and send you your official tax receipt

Debit Order I wish to sponsor by debit order an amount of .................................. to The Chancellor’s Annual Fund, University of the Witwatersrand on the first day of ............................ 2008 and each month thereafter. Account No.: ................................................................................................... Type of Account: Current Transmission Savings Bank/Building Society: ................................................................................... Branch Name & Address: ............................................................................... .......................................................................................................................... City/Town: ......................................................... Branch Code: ..................... Signature: ............................................................. Date: ................................ (as for signing cheques)

Tel. No. (H): (.......) ..................................... (B): (.......) ..................................... Name : ............................................................................................................. Address: .......................................................................................................... ......................................................................... Postal Code: .........................