If you wish to set up a regular (monthly, quarterly or yearly), payment, please print out this form and send it to us at the address below.

The Ralph Bates Pancreatic Cancer Research Fund.

Direct Debit Form

• Please complete your name and address below

Name: Mr/Mrs/Ms/Miss:

Address:

Postcode:

Telephone (in case we have a query):

• I/we wish to make the following gift:

Monthly/quarterly/yearly:

Amount: £

I would like the payment to be made on:

(Please make the start date at least one month from today).

• Please complete the following;

To: The Manager,……………………………………………………...Bank/Building Society.

Full postal address:

Postcode:

Name(s) of account holder(s):

Bank/Building Soc Account Number:

Bank sort code: -- --

Instructions to your Bank/Building Society; Please pay to The Ralph Bates Pancreatic Cancer Research Fund, Direct Debits from the Account detailed above subject to the safeguards assured by the Direct Debit Guarantee (see next page).

Signature(s): Date:

• Please mail this form (we suggest you keep a copy) together with a completed Gift Aid Declaration (if you are a UK Tax payer) to:

The Ralph Bates PCRF,

317 Old Bedford Road, Luton, LU2 7BL, United Kingdom.

• Receipt will be acknowledged.

The Direct Debit Guarantee.

Please print and retain a copy of this guarantee.

• This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme. The efficiency and security of the Scheme is monitored and protected by your own Bank or Building Society.
• If the amounts to be paid or the payment date changes, The Ralph Bates Pancreatic Cancer Research Fund will notify you 10 working days in advance of your account being debited or as otherwise agreed.
• If an error is made by The Ralph Bates Pancreatic Cancer Research Fund or your Bank or Building Society, you are guaranteed a full and immediate refund from your branch of the amount paid.
• You can cancel a Direct Debit at any time by writing to your Bank or Building Society. Please send a copy of your letter to us.