Bankers Order Form

Your Bank or Building Society

Your Bank's Name____________________________________________

Your Bank's Address _________________________________________

___________________________________________________________

Your Bank's Postcode________________________

Name of account Holder _____________________________________(ie the name on your chequebook)

Account Number _ _ __ ____ _ __ _ (ie your account)

Bank Sort Code _ _ __ _ __ _
(The 6 digits from top right of your cheque book)

Your Instructions to your Bank or Building Society

To the Manager:

Please pay to the order of Relief Fund for Romania (Account number 00424195, Sort Code 12 11 03, Bank of Scotland 12/14 Cockspur St, London W1)

The sum of £_____ now and monthly instalments of £____ thereafter until ___ or when countermanded by me in writing quoting the above reference number when processing payment.

Signed _________________________________

Print Name _____________________________

Your phone number _____________________

Thank you. Please SEND THIS TO:

Relief Fund for Romania, 54/62 Regent St, London, W1B 5RE