PAYROLL GIVING FORM   NOTIFICATION OF 
PAYROLL GIVING
(Please complete in BLOCK CAPITALS and hand it to your employer) | Please complete this form and send to:
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I would like to give tax free from my pay to: |
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The Dyslexia Institute

The Dyslexia Institute Bursary Fund
(Please tick as appropriate)

Amount of donation each pay day:
(Please tick as appropriate)

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Community Fundraising
The Dyslexia Institute
FREEPOST SEA 3988
EGHAM
TW20 0BR

From:

Monthly | Title: ................................................
£25 £15 £10 £5 |

4- Weekly		 |
|		 Name: ..............................................................................
£25 £15 £10 £5 | Address: ..........................................................................

Weekly		 |
|		              ..........................................................................
£10 £8 £2 £1 |              ..........................................................................
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Other £ ........................  and period  .......................... | Post Code: .........................
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Title:  ..................................... | Telephone: .................................
Name: .......................................................................................... |
Address: ....................................................................................... |
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|		 This is to notify you that my Payroll Giving
 donations will be coming to you through 
our Payroll Agency.
               ....................................................................................... |
               ....................................................................................... |
|		 My pledged amount is £. . . . . . . . week / month  
starting on the . . . . (day) of . . . . .  (month / year)
Post Code: ........................................ |
|		 Employer: ..................................................................................................
(Name in full)
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Employer: ...................................................................................... |
|		 Workplace Address:  .............................................................................................
(Name in full) |                          ...................................................................................
Workplace address: ....................................................................... |
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....................................................................................................... |
Post Code: ....................................... | Post Code: .....................
Employee / Staff No:  ........................................... | I wish my donation to go to:
Signature: ............................................................. |
Date: ................................................ |
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The Dyslexia Institute

The Dyslexia Institute Bursary Fund
(Please tick as appropriate)

I do not wish my details to be passed to other voluntary organisations.

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