Please pay Barclays Bank plc, Dorchester
Sort Code: 20-26-62
Account Number: 40777188

the sum of (amount in words)......................................................................................

£ ............................................................................................................................

commencing on .......................................................................................................

and thereafter every 1st JANUARY ANNUALLY until further notice in
writing and debit my account accordingly.

Account to be debited: .................................................................................................

Account No: ................................................ Sort Code: ...............................................

Signature: ..................................................................................................................

Date: ........................................................................................................................

Name (BLOCK CAPITALS)................................................................................................

Address: ....................................................................................................................

.................................................................................................................................

.................................................................................................................................

Post Code: .................................................................................................................