Please fill out the boxes below, print this page out, sign and date it, and forward to the freepost address shown at the bottom of the page:
| 1. | Name: | |
| Address: | ||
| Postcode | ||
| Telephone: | ||
| Email: | ||
| 2. | Please pay Winchester Liberal Democrats, £ each month until further notice and debit: | |
| 3. | Account number: | |
| 4. | Name(s) of Account Holder(s) | |
| 5. | Bank Sort code: | |
| 6. | Starting on: |
Please allow one month from now |
| 7. | Signatures |
_____________________________________ |
| 8. | Date: |
_____________________________________ |
| 8. | To Manager
(Bank name and address) |
Postcode: |
| 9. | Please return this form to following FREEPOST address:
Winchester Liberal Democrats, The Granary, Barton Farm, Andover Road, Winchester, SO22 6AX |
|
For office use only:
Lloyds Bank, High St, Winchester (30-99-71) for the credit of Winchester Liberal Democrats A/C No. 00126572