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Impact Radio Club Card - New Application

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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)

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Branch

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

Amount

Monthly or Yearly Choose a value Monthly Yearly

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