STOPORDER CLEARANCE

1.                   APPLICANT  :

I, the undersigned, ______________________________________,

Account number __________________________________________ at

__________________________________ Bank code ____________,

request you to debit my account with  :

On the_________ day of each month, starting on ____/____/_____.

My postal address is  :  ____________________________________________

Identity number  :   _____________________________________

Telephone number                      :   ________________(w) _______________ cell

2.                   DETAILS OF BENEFICIARY  :

NAME                           :           OOSTERLAND YOUTH CENTRE

BANK                           :           ABSA DESPATCH

CHEQUE ACCOUNT.     :           9061914700

BRANCH CODE            :           334516

___________________     _____________________         _____________

SIGNATURE                     NAME                                   DATE