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
Date
Back
Next
Direct Debit Set Up
prev
next
( X )
Benefactor Contribution
(
GBP
for each
year
)
Total
£
0.00
Submit
Should be Empty: