Request for Bank Standing Order

Friends of Mulanje Orphans UK Charity No 1090727

Please and complete the form.

The completed form to handed in to your bank or returned to:

FOMO, 29 Liverpool Old Road, Walmer Bridge, Preston, Lancashire PR4 5QA

Payment Details

SINGLE gift of

£

Transfer Date

and/or MONTHLY Donation of

£

Date From

Account Holders Details: (Please complete in BLOCK CAPITALS)

Title (Mr. Mrs. Ms. Dr. other)

First or Given Names

Family / Surname

Address

Post Code

Telephone No

Email Address

Account Details:

Your Account Details:

Recipients Account Details

Account Name:

Friends of Mulanje Orphans

Sort code:

30-96-85

Account Code:

2394580

Bank Address:

Lloyds TSB Bank plc

94 , Fishergate,

Preston,

Lancashire

PR1 2JB

This is to authorise payment as indicated above to account name of:

'Friends of Mulanje Orphans' Sort code: 30-96-85 Account no 2394580

Please Print Account Holders Name

Account Holders Signature

Date: