Regular monthly donation to
Health Aid UK
by standing order

Please print this form - fill it in - and pop it in the post.

Your full name_________________________

Your address_________________________

_________________________

Your post code_____________

Your telephone number_________________________

THE MANAGER

_________________________(your bank)

_________________________(Bank address, if known)

_________________________

____________(Post code, if known)

I will support Health Aid UK with a regular monthly gift of:

Amount in figures _____ Amount in words ______________________


The payments should leave my account on the _______ (day) of each month. (If left blank, the payment day will be the working day after the form is first accepted by your bank.)

My account number is ______________ Bank Sort Code ___-___-___

Signature____________________ Today's date ____________

Notes:
HEALTH AID UK collection account: SC 05-07-22, AC 24870305

UK tax payers may wish to convert this monthly gift into a covenant, which increases it's value to Health Aid UK. To receive further information about this, please tick here [ ].

Please remember to send this form to Health Aid UK - not to your bank. Thank you.
Please send this form to:
Health Aid UK
80 Spotland Road
Rochdale
OL12 6PQ
UK