Doctors and Lawyers for Responsible Medicine
 

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Doctors & Lawyers for Responsible Medicine

Standing Order Form

Amount donated:

£10 £20 £50 £100 £500 £1000 Other £______

Bankers' Order Mandate:

Your Bank Name: _________________________________
Bank Address: _________________________________

Please pay Barclays Bank Plc - Crouch End Branch A/c No: 60523755 the sum of (words) __________________ / (figures) £   :   p annually* / monthly* thereafter until countermanded (delete as appropriate)

My account number: _________________________________
Account name: _________________________________
Signed: _________________________________
Dated: _________________________________
Address: _________________________________

Please print, complete and send to:
DLRM, P.O. Box 302, London N8 9HD

DLRM is a company limited by guarantee. Reg no. 1700757, England

Thank you for your support.

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