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: