Sixmilebridge GAA Development Fund

Payment by Standing Order

Request for Standing Order

To: The Manager (Bank Name) : ___________________________________

You are authorised to set up a standing order on my/our account as specified below. My/Our account will at all times contain sufficient funds to enable each payment to be effected on the due date.

Name (Print) ______________________________________        Date: ___________________

Address: _____________________________________________________________________

Please Charge To My Account

A/C Num: ______________________      Sort Code: _________________

Type of Account: _________________________

Payment Account Ref Num: _________________

Your Name: _____________________________

Sixmilebridge GAA Development Account:

Sort Code Num:  93-54-84

A/C Num: 04246098

Payment Option : __________________________

Start Date : _______________________________    Amount : ________________

Expiry Date : ______________________________

Signature : ________________________________

Print Standing Order

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