Claim form — independent, african, global media and publishing

Stipend and funds claim form

Please complete this form to claim funds allocated to you as a member of the as-yet-unnamed writers' commune hosted by Collective Media Cooperative Limited.

Name

First Name

Last Name

Payment details

What are you claiming?

Please select all that apply.

Stipend

Childcare fund

Digital connectivity

How would you like your stipend to be paid, all up front or monthly between now and November 2023?

Please note that the digital connectivity fund is paid monthly from August 2023 and the childcare fund upfront before the retreat.

All upfront

Monthly

Your bank account details

Which bank do you use?

What is your account number?

What is the branch code?

Please provide the SWIFT code or IBAN if it is not a South African account.

What is the account name (if different from your name)

Is there any other payment information we would need or you would like to share?

Stipend and funds claim form

Collective Media Primary Co-operative Limited