|
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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