Please complete this form and send it back to us at:
Outlook Bursary Fund, c/o
To Bank
Bank
Postal Address
Post code
Please pay: HSBC
for the credit of: Outlook Bursary Fund
Sort Code 40-44-37 Account No. 11658751
the sum of:
Please
tick as appropriate:
q
£2
q
£5
q
£10
q
£25
q
Other Amount (please specify)
£
Date of first payment .
and thereafter every
Due day .. Frequency .. (weekly, monthly, quarterly, annually)
until further notice in writing or Date of last payment ..
and debit my/our account accordingly
Name of Account to be debited
Sort Code . Account number .
Signatures(s)
Date