BANK STANDING ORDER MANDATE:

To Manager of:

Branch Address:

Please debit my / our account No.

With £ Commencing on 1^st October 200

_

And thereafter Annually on 1^st October until you receive further notice from me in writing.

And pay: ROYAL BANK OF SCOTLAND PLC

38-41 STATION STREET

BURTON ON TRENT

DE14 1AX

SORT CODE: 16-14-70

For the credit of: BURTON RUGBY FOOTBALL CLUB – PROMOTIONS A/c

Account Number 10088020

Name:

Address:

Signed: Date:

Please send completed mandate to: Mrs J M Bullock - BRFC Membership

14 Stapenhill Road

Burton-on-Trent

Staffs

DE15 9AF