1st floor, Hillborough Road, Westcliff-on-Sea, Essex, SS9 0SG. We will add your membership to our ... Thank you for your
Lady McAdden Breast Screening Trust 500 Club Application Full name:
Tel No:
Full address:
Postcode: e-mail address: Bank/Building Society: Bank/ Building Society full address:
Postcode: Sort Code:
Account Number:
Does this standing order replace an existing standing order? YES NO Delete as appropriate I wish to pay: £15 quarterly £60 annually Delete as appropriate Recipient: Lady McAdden Breast Screening Trust Recipient bank Details: Lloyds Bank, Kent Elms Corner Sort code: 309784 Account no. 2437846 Special instructions: Signature:
Date:
Please complete this form and return to: Lady McAdden Breast Screening Trust 1st floor, Hillborough Road, Westcliff-on-Sea, Essex, SS9 0SG We will add your membership to our records and forward the completed form to your bank to commence payments. Please call 01702 343288 if you have any queries Thank you for your support. We will contact you with your draw number First draw will take place October 2015
For Office Use Only 500 Club Membership Number________
