I / We Would Like to Make a Gift of ______To UCT Faculty of Health Sciences

1

UNIVERSITY OF CAPE TOWN
FACULTY OF HEALTH SCIENCES
Donation form
Alumni & Bequest officer
UCT Faculty of Health Sciences
Private Bag X3
Observatory, 7935
South Africa
I would like to make a donation to be utilised in the following area:

Bursary support

Students in Distress: our project to assist students with day-to-day needs

Books for the Medical Library

I / we would like to make a gift of ______to UCT Faculty of Health Sciences

/ Cheque:
Enclosed is R______(Payable to UCT)
/ Credit card:
Amount: ______

Please charge my VISA Mastercard American Express Other
Account Number: ______Expiry Date: ______
Card name (eg Dr JR Soap: ______
Security No (Last 3 digits on the back of the card) ______
Signature: ______
/ I pledge to subscribe over the next 5 years the total sum of R ______
in annual instalments of R______First contribution to be made on _____/_____/_____
Monthly debit order:
R______x 60 months.
Account No : ______
(Transmission or Current Accounts only)
Bank/Building Society ______
Branch name and address ______
Branch Code
______
/ Direct deposits and EFT
Bank: Standard Bank of South Africa, Rondebosch
Account name: UCT No 1 Account
Branch Number: 02 50 09
Account Number: 07 150 3854
Type of Account: Current Account/Loan Account
Reference: Medical 1959 initials and surname
i.e. Medical 1959 JR Soap
VERY IMPORTANT: Please forward a copy of your deposit slip to
the Alumni Office – for attention: Joan Tuff Fax: +27 21 447 8955

All gifts are tax deductible under Section 18A of the Income Tax Act

Thank you for your support

Contact details (you may wish to remain anonymous but having your contact information enables

the University to acknowledge your gift and send you a tax certificate)

Name:
Home Address:
Postal Code:
Telephone (H): / Telephone (W):
Fax: / Email: