Hampshire Branch : Bankers Order

PLEASE COMPLETE IN BLOCK CAPITALS

To:

Name of Bank:

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Address of Bank:

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Postcode of Bank:

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Sort Code:

...... - ...... - ......    Account No: ........................

Please pay to the Jane Austen Society (Hampshire Branch) at HSBC, Eastleigh Branch, Hampshire, (Sort Code 40-20-10, Account No. 61409484) the sum of £...................... with immediate effect, and continue to pay this sum annually from 1 January next until further orders in writing from me. Please debit my account for these payments.

Name:

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Address:

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Postcode:

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Signature:

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Date:

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