Standing Order Mandate Form

Standing Order Mandate Form
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City County

Eircode
Phone Number *

Area Code Phone Number
Your Bank Details
To the Manager *
Name of Bank/Building Society
Branch Address *

Street Address

Street Address Line 2

City County
Your Account Details
I authorized you/the bank to debit my account using the details below:
Bank Name *
Branch Name & Location *
Account Number *
Account Name *
Sort Code Number *
IBAN number *
BIC *
Payment Details
I request that you pay to the Bank of Ireland, Main St, Dundrum, Dublin 14 (90-10-95) for credit to account Agapé Ministries Ireland, IBAN IE09BOFI90109582 813960, BIC: BOFIIE2D
Amount
Amount *

€21* €30 €50 Other
*Tax Reclaim: any donation of €250 (€21 monthly) from a PAYE or self-assessed tax payer, Agapé can reclaim the tax on your donation at the flat rate of 31%. This means your donation can be worth an additional €112.32, at no additional cost to you. The reclaim will be credited to your designation.
Amount in words *
Frequency *
Start Date *

Month Day Year
Date
Staff member or Project Designation *
Date Signed

Month Day Year
Date
Signature

Clear
Please keep me updated about Agapé via:

Email Post
Should be Empty:

Your Bank Details