THURSO FC 100 CLUB MANDATE

TITLE FORENAME SURNAME

ADDRESS

TELEPHONE NUMBER

MOBILE NUMBER

POSTCODE ____________________ E-MAIL ADDRESS_______________________

NAME OF BANK ACCOUNT HOLDER

SORT CODE BANK ACCOUNT NUMBER

NAME & ADDRESS OF BANK

£21.66

MONTHLY PAYMENT SIGNATURE

"

INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY BY STANDING ORDER

Please complete parts 1 to 4 to instruct your bank to make payments directly from your account to that of Thurso Football Club, Bank of Scotland, Sort Code: 12-20-26, Account No: 06193011

1. Please write the full postal address of your bank and branch in the box below

2. Name of the Account Holder(s)

3. Sort code Account Number

4. Instruction to your bank or building society and signature

· I instruct you to pay a standing order from my account to Thurso FC as noted above for the amount of £21.66 per month.

· Payments are to commence on -----------------------------------------------------------

· I will inform the bank in writing if I wish to cancel this instruction

Signature Date