| Friends of the Dyslexia Institute | |
| Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | |
| Address. . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
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| .
. . . . . . . . . . . . . . . . . . . Post Code. . . . . . . . . . . . .
. . . . |
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| Telephone
No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Please tick below as appropriate) |
|
I
enclose my cheque/PO for £10.00  (Due on 1st August each year) |
Please
find my completed Standing Order below. |
| I
wish to pay my annual subscription of £ . . . . . . by credit
card (Access
/Visa)
(please tick) |
|
and
my number
is:
 |
|
| Expiry date . . . . . / . . . . . . | Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| ............................................................................................................................................................................... | |
| BANKER'S STANDING ORDER | |
| To . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . Plc (name of your bank) |
|
| Branch
address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| . . . .
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. . . . |
Date . . . . . . . . . . . . . . . . . . . . . . |
| . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Bank
Sort Code |
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Bank
Account no. |
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Post Code . . . . . . . . . . . . |
|
| Starting on the . . . . . . . . . . . . . (date) and on the same day* in each year please pay the sum of £ . . . . . . . . . . | |
| (amount in words) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | |
| until further notice to The Dyslexia Institute | |
| (A/C no. 03194907) at Lloyds TSB Bank plc., | |
| 215 High Street, Hounslow, Middlesex, TW3 1DN | |
| Sort code: 30-94-42 | Return
to Sue Hazlem at: The Dyslexia Institute, FREEPOST SEA3988 Egham , TW20 0BR Registered Charity Number 268502 |