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BASIN HEARTWATCH 200 CLUB

STANDING ORDER MANDATE

To:    Bank Bank
Address:		  

Ticket relevant box. Add reference/beneficiary if amending a previous standing order.

  New Instruction   Please amend previous standing order.   Reference/Beneficiary

Account to be debited

Sort Code   Account
Number		   Account
Holder's Name		  

Beneficiary details

Bank:  HSBC            Branch:  72 High Street, Maldon, Essex CM9 5ET            Sort Code:   40-31-35
Account Number:   21333046                Beneficiary:  Basin Heartwatch 200 Club

Payment details

Amount of first payment £ Date of first payment  
Amount of usual payment £ Amount of usual payment in words   

Usual payment paid monthly on the 1st day of each month.

Customer's signature   Date  

After your numbers have been allocated we will forward this form to your bank for processing.