Mid-Antrim Animal Sanctuary Direct Debit Payment Form

INSTRUCTIONS TO BANK/BUILDING SOCIETY - fill out, print and sign.
(If you cannot print this form for any reason, please contact us at contact@midantrimanimalsanctuary.org
and we'll post you out the appropriate forms.)

I (name of account holder)
authorise the Manager at
  
(name and address of bank/building society)
  
to debit my account: number
Sort Code:
- -
the amount of: £
on (date):
of each month
commencing
/ /
until further notice.
  
   
MID-ANTRIM ANIMAL SANCTUARY
NORTHERN BANK LTD
42 High Street, Antrim, BT42 4AP
Sort Code: 95-02-02
 Account Number: 81176242
   
Signed..................................................................................................................................
(account holder)  
 
Date.....................................................................................................................................