PLEASE COMPLETE IN BLOCK CAPITALS

To:

Name of Bank:

...........................................................................

Address of Bank:

...........................................................................

...........................................................................

...........................................................................

Postcode of Bank:

.........................

Sort Code:

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

Please pay to the Jane Austen Society, at Lloyd's Bank plc, 40 High Street, Alton, Hampshire GU34 1BQ (Sort Code 30-90-15, Account No. 0097714) the sum of £............... to commence on (please insert date)............................ and continue paying that amount annually until further order in writing from me. Please debit my account with you for such payment. This cancels all existing orders in favour of the Society.

Name:

........................................................................

Address:

........................................................................

........................................................................

........................................................................

........................................................................

Postcode:

......................................

Signature:

..................................................................................

Date:

.......................................