Yearly membership subscription Standing Order Request
PLEASE SUBMIT THIS TO YOUR OWN BANK AND NOT NCCC
Your Bank details
Name of Bank______________________________________________
Bank Address______________________________________________ ______________________________________________ ______________________________________________
SORT CODE______________________
ACCOUNT NUMBER______________________
NAME/ NAMES ON A/C______________________
I/We authorise you to debit the above account with the sum of (please tick)
Single Membership for £3.00
Joint Membership for £4.00
On 1st January 2011 and yearly thereafter until further notice
Signed______________________________Date _______
Payable to
Northern Counties Chihuahua Club
Bank detailsRoyal Bank of Scotland Poulton-le-Fylde Branch 1 Market Place Poulton-le-Fylde Lancashire FY6 7AT
