Becoming a Patron of Adderbury Library

PATRON APPLICATION FORM

I/we wish to become a Patron of FOCAL at a cost of:-

£100.00 per annum per person or per couple

 

NAME(S)
ADDRESS  

 

TELEPHONE
EMAIL

 

Payment Options

– I enclose a cheque for £100.00 made payable to Adderbury Library Action Committee

– I wish to set up a standing order for £100.00 per annum (see below)

Please treat as Gift Aid donation (from taxed income)

Tick the box if you wish to do this

Confidentiality:

I/we wish/do not wish my/our name(s) to be entered on the Patron’s Roll in the library *

*Please delete as appropriate

 

Signature:

 

  Date:  

Standing Order Mandate

To: The Manager, Bank/Building Society:
Address
Sort Code: –                – Account No:
Payment Instructions:
Pay the sum of: £100.00 ONE HUNDRED POUNDS
On: (date eg 1 July) Each year until cancellation
To:   Bank: LloydsTSB plc, 12 High St Banbury   Oxon Sort Code: 30-90-42     Account No: 07291653

Account Name: Adderbury Library Action Committee

 

Signature: