Welfare Fund Standing Order Form

For Welfare Funds

Border Collie Rescue, 57,Market Place, Richmond, North Yorkshire, DL10 4JQ. 0870 4445838

To make regular standing order payments to Border Collie Rescue, please fill in this mandate and hand it in to your bank. Please Use Block Capitals.

TO ___________________________________ Bank. Sort Code _ _ _ _ _ _ :

Branch______________________________________________________:

A. Customers details.

Account Name _____________________________:

Account Number _ _ _ _ _ _ _ _:

Tel Number - Work __________________: Home ___________________:

Please set up the following standing order and debit my/our account accordingly -

B. Beneficiary details.

Pay to the account of BORDER COLLIE RESCUE WELFARE FUND at NATIONAL WESTMINSTER BANK - MARKET PLACE - RICHMOND - NORTH YORKSHIRE.

Account Number 4 6 1 6 5 4 0 1 Sort Code 5 4 - 3 0 - 4 3

Reference to be quoted (if any)_______________________________________:

C. Payment details.

Please Pay to the above beneficiary -

The sum of Ł________: In words______________________________________:

Commencing On _____________________date and thereafter Monthly.

Total Number of Payments _____ OR Expiry date __/__/____ OR Until Further Notice ___ Tick.

I / We acknowledge that the bank will not undertake to : (1) make any references to VAT or other indeterminate element - (2) advise payees address to beneficiary - (3) advise beneficiary of inability to pay - (4) request beneficiaries banker to advise beneficiary of receipt

Customers signature/s _____________________________________________________:

Date _____________________:

Bank Use Only - Keyed By __________ (initials). Date ________________:

Served By ______________________ at __________________________ Branch

ITS No _____________________ External No ______________________