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IMPACT RADIO CLUB CARD

Impact Radio Club Card - New Application

Please complete the form below and we'll get back to you

ID number

Title

Initials

Name and surname

Work number

Cell number

Email address

Postal address

Postal code

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Debit Order Details

I authorize Impact103 and my bank named below to charge my account monthly on one of the below mentioned dates. This will remain in effect until I give written notice to cancel it.

Type of bank Account (e.g savings)

Bank account number

Bank

Branch

Branch code

Date of deduction Choose a value 1st 10th 15th 20th 28th End

Amount

Monthly or Yearly Choose a value Monthly Yearly

Please solve the math problem and enter the answer in the box below it    

 

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