To.................................................................................Bank

..................................................................................Branch

Address..................................................................................

.............................................................................................

Sort Code………/………/……...

Please pay on……………………………………..(date of first payment)

to National Westminster Bank plc, Street Branch (Sort Code 60-21-01) the sum of £10 (ten pounds)

For credit to the account of Glastonbury Antiquarian Society (account no, 51035367) and next on

1st September 2008 and thereafter annually on 1st September each year until further notice,

charging such payments to

my………………………………... Account, numbered…………………….

THIS CANCELS ANY EXISTING ORDER IN FAVOUR OF GLASTONBURY ANTIQUARIAN SOCIETY

Signed..................................................................................

Date..........................................

Member's Name (please print)………...........................................................................
 

This form should be presented at the local branch of your bank for processing.