FAMILY VALUES SUBSCRIBERS PAYMENT FORM

A) GIFT:      I undertake to give a gift of ...............................................................................................................................      to the Christian Coalition.(E.g. Computers, faxes, vehicles, etc.)

B) DONATION: (by Postal Order or Cheque) I undertake to give R ................................................................ monthly Herewith a once only payment of R ............................................ I will deposit R ................................ directly into the Christian Coalition Bank Account No. 9516226499, NBS Bank Hillcrest Branch (Code 51-00-02), KZN, South Africa I would like to bequeath ............................................................................................... (e.g. Land, money, property, etc.) to the Christian Coalition.

C) MONTHLY DEBIT ORDER / CREDIT CARD INSTRUCTION: Account.No: Account Name: .......................................................................................................................... Name of Bank: .................................................................. Branch: ..................................................................................... Branch.Code: Type of Account:   Cheque[    ]     Transmission[    ]    Savings[    ]    Visa[    ]     Mastercard[    ] Expiry Date: (Credit Cards only)................................................................................................... Amount: R ..................................... In words: ...............................................................................................................................

Day of the month on which account must be debited: .............................. (Eg. 1st / 17th / 25th) With effect from (date):................................................................................................................ Signed at ............................................................................ on this ............... day of ........................................................ 1999   AUTHORISED SIGNATURE: ..........................................................................................