Direct Debit Form

To: The Manager

__________________________________ (Bank Name)

__________________________________ (Bank Address)

_______________________Postcode:______________________

Account Name: ________________________________________

Account Number: ­______________________________________

Please pay £ _______(sum) starting on the ______________ day of____________ (month)

and on the same date each month/year until further notice to the Bank of Scotland, 54 John Street, Aberdeen AB25 1LL (Sort Code 80-05-16) for the credit of Grampian Society for the Blind, account number 00137509, quoting ref. ________ (leave blank).

Signature:___________________ Date: ____________________

(please print)

Name: ________________________________________________

Address: ______________________________________________

_____________________________Postcode_________________

Please return to: Grampian Society for the Blind, 21 John Street, Aberdeen AB25 1BT

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