Bansang Hospital Appeal - Direct Debit Mandate
PLEASE COMPLETE ALL BOXES MARKED WITH ' > ' ~ IN BLOCK CAPITALS.
Your Details
Full Name	>
Your address	>
	>
	>
Country	>
Your Bank Details
Bank name	>
Bank address	>
	>
	>
Country	>
Account to be debited (Name)	>
Account number	>
Sort code	>
Your Donation Details
Amount of payment -  £ or  $	>
Amount of payment - in words	>
Frequency  ( Monthly / Yearly )	>
Commence on  ( Month and year )	>
Continue until  ( Month and year ) leave blank if next option applies	>
Continue until further notice ( Yes )	>
Your signature
Date	>
Beneficiary Details
Bank	Barclays Bank Plc.
Address	High Street, Kettering, Northamptonshire, England
Account name	Bansang Hospital Appeal
Account number	50047910
Sort Code	20-45-77
Bansang Reference