Bank

Branch address

Sorting Code Number

please pay

HSBC

110 Watling Street, Towcester, Northants

   40  -  44  - 26

Beneficiary’s Name

Account Number

Quoting Reference

for the

credit of

Towcestrians Hundred Club

1

1

2

2

4

5

7

3

(2)…………………………………

Amount

Amount in words

the sum of

£ 5.00

Five pounds only

Date of first payment

and thereafter every

Due date and frequency

until further notice in writing or

Date of last payment

and debit my/our account accordingly

commencing

28th (3)…………… 2003

Month

28th of the month

PLEASE CANCEL ALL PREVIOUS STANDING ORDER/DIRECT DEBIT MANDATES IN FAVOUR OF

UNDER REFERENCE NUMBER

Account to be debited

Account Number

(4)

(4)

Special instructions