Wiltshire Blind Association

Standing Order Mandate

Donor details: Name…………………………………………………………….

Address…………………………………………………………………………….

…………………………………………….Post Code……………………………

Donor’s Bank: Name…………………………………………………………….

Address…………………………………………………………………………….

…………………………………………… Post Code…………………………….

Sort Code…………… Account number…………………………………….

From the aforementioned account, please pay the HSBC Plc, Devizes Branch, Sort Code 40-19-16, Account Number 61406396 for the credit of the Wiltshire Blind Association the sum of:

Amount:…………………….in words…………………………………………..

Annually on the…………..day of ………………..until altered or stopped by me.

Signature …………………………………………

Date………………………………………………..

This form must be returned with the application

form completed overleaf by the end of the month prior to the first

month you wish to enter the draw.