Golden Bird Patrons Application Form

Personal Information

Title

First Name

Surname

Identity Number

Date of Birth

Company / Trust Name

Contact Details

Telephone (Work)

Mobile Number

Email Address

Address

Physical Address

Postal Code

Postal Address (if different from physical)

Postal Code

Patron Category

Please select your preferred giving tier:

Select Category

Golden Pipit — R100 000 per annum Golden-breasted Bunting — R75 000 per annum African Golden Weaver — R50 000 per annum African Golden Oriole — R25 000 per annum

Section 18A Tax Certificate Information

Required for your tax-deductible donation certificate. Complete if your details differ from the personal information above.

Full Name of Donor / Company / Trust

Unit Number

Complex / Building Name

Street Number & Name

Suburb

City

Postal Code

Postal Address (if different from physical address)

Postal Code

Identification / Passport / Company Registration Number

Identification Type

Identification Number

Country of Issue

Tax Reference Number

Contact Person

Contact Tel / Cell Number

Contact Email Address

Proof of Payment

Please attach your proof of payment. Remember to reference your payment with your name, surname and GBP.

Upload Proof of Payment

Declaration

I confirm that the information provided is accurate and I agree to become a Golden Bird Patron of BirdLife South Africa.