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

By completing this form, you give permission for Focal to hold your personal information. We will only use this information to inform you of news about the Library and Friends events, appeals and renewals of memberships. You may withdraw this consent in writing at any time.  We take your privacy seriously and store your data securely.  Your data will not be shared with any other organisation.

Payment Options

– I enclose a cheque for £100.00 made payable to Focal

– 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: Lloyds plc, 12 High St Banbury   Oxon Sort Code: 30-90-42     Account No: 07291653 Account Name: Focal
Signature: