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 |
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TELEPHONE | |
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:
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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 |
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Signature: |