| To: The Manager, | |
| Bank Name | ________________________________________ |
| Bank Address | ________________________________________ ________________________________________ ________________________________________ ________________________________________ |
| Bank Post code | ____________________ |
| Sort code | ______-______-______ |
| Please pay | Girobank plc, Merseyside. GIR 0AA |
| for the credit of | OutRage! account no. 77.80.93.02, sort code 72-00-01 |
| the sum of | £ _______________________________________ |
| monthly / quarterly / annually* (delete as appropriate) | |
| starting on | ________________________________________ until further notice. |
| Account to debit: | ________________________________________ |
| Account number: | ________________________________________ |
| Signature: | ________________________________________ |
| Date: | _________________________________-200___ |
SEND TO YOUR BANK, (not to OutRage!)