Direct Debit Mandate Form 1

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=0 style="border-right: 1px solid #CCCCCC;" BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <B>To print this form scroll to bottom of page</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B>          Go back to: </B></FONT><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="id80_direct_d_1.htm" TARGET="_top" TITLE="Donate Money"><B>Donate Money</B></A></FONT></div> <div> <TABLE BORDER="1" CELLPADDING="3" CELLSPACING="0" WIDTH="589" BORDERCOLORLIGHT="#111111" BORDERCOLORDARK="#111111" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=2 HEIGHT= 25 ><NOBR><div> <B>Bansang Hospital Appeal - Direct Debit Mandate</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=2 HEIGHT= 22 ><NOBR><div> PLEASE COMPLETE ALL BOXES MARKED WITH ' <FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B>></B></FONT><FONT SIZE="2" COLOR="#FF0000" FACE="Arial" ><B> </B></FONT>'<FONT SIZE="2" COLOR="#111111" FACE="Arial" > </FONT> ~ IN <B>BLOCK</B> CAPITALS.</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=2 HEIGHT= 16 WIDTH="573"><div> <B>Your Details</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Full Name</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Your address</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 17 WIDTH="198"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="17" ALIGN="bottom" WIDTH="198" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="198" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Country</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=2 HEIGHT= 16 WIDTH="573"><div> <B>Your Bank Details</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Bank name</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Bank address</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="198" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="198" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Country</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>>                                                              </B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 ><NOBR><div> Account to be debited (Name)</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Account number</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Sort code</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=2 HEIGHT= 16 WIDTH="573"><div> <B>Your Donation Details</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 ><NOBR><div> Amount of payment -  £ or  $</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 ><NOBR><div> Amount of payment - in words</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 ><NOBR><div> Frequency  ( Monthly / Yearly )</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 ><NOBR><div> Commence on  ( Month and year )</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 32 ><NOBR><div> Continue until  ( Month and year ) </div> <div> leave blank if next option applies</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 ><NOBR><div> Continue until further notice ( Yes )</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 48 WIDTH="198"><bR> <div> Your signature</div> <bR> </tD> <tD VALIGN=CENTER WIDTH="373"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="48" ALIGN="bottom" WIDTH="373" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Date</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> <B>></B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=2 HEIGHT= 16 WIDTH="573"><div> <B>Beneficiary Details</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Bank</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> Barclays Bank Plc.  </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Address</div> </tD> <tD VALIGN=CENTER><NOBR><div> High Street, Kettering, Northamptonshire, England</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Account name</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> Bansang Hospital Appeal</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Account number</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> 50047910</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Sort Code</div> </tD> <tD VALIGN=CENTER WIDTH="373"><div> 20-45-77</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 16 WIDTH="198"><div> Bansang Reference</div> </tD> <tD VALIGN=CENTER WIDTH="373"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="373" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div>  <form><input name="Print" onClick="window.print();return false" type="button" value="Print this form"></form>  </div> <div> <B>Go back to: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="id80_direct_d_1.htm" TARGET="_top" TITLE="Donate Money"><B>Donate Money</B></A></FONT></div> <bR> <bR> </td> <td valign="top" width=0 style=" border-left: 1px solid #CCCCCC;" BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> </td> </tr></table></body>