Benefactor Application Form
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
-
Country Code
Phone Number
I wish to contribute an annual sum of:
*
£300 (minimum)
£400
£500
Other
Please tick as appropriate below:
*
I already have a direct debit in place to The T&RA and am happy for this to be changed to reflect the above contribution
I would like to set up a direct debit via GoCardless to reflect the above contribution
Signature
Today's Date
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Benefactor Contribution
(
GBP
for each
year
)
Submit
Should be Empty: