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Weston Hospicecare

Title(s)_________ Initial(s)___________ Surname(s) _________________________________________

Organisation _________________________________________________________________________ 

Address ____________________________________________________________________________

                ____________________________________________________________________________

Postcode _______________

Telephone Numbers - Daytime ______________________  Evening _________________________

1.    I wish to make a donation of £____________________ A receipt is/is not required.

2.    I wish to make a donation in memory of ____________________ of £__________.
       A receipt is/is not required.

Please make cheques payable to 'Weston Hospicecare'

Gift Aid Declaration - PLEASE COMPLETE

3. Gift Aid Declaration

I am a UK tax payer and pay an amount of Income Tax and/or Capital Gains 
Tax at least equal to the tax that can be reclaimed on my donation.

Please treat any donations I have made since 6 April 2003
 and all future donations that I make to Weston Hospicecare
 until I notify you otherwise, as Gift Aid Donations.

Signed____________________________   Date___________________

Regular Donation - Bankers Order Form

I wish to support Weston Hospicecare with regular donations of £___________ a month/year, and have completed the Bankers Order Form below and the Gift Aid Form (if applicable).

To: The Manager (Name and full address of your bank or building society)

_____________________________________________________________________________________

_______________________________________________ Postcode _______________

Please pay Weston Hospicecare Ltd £________, (amount in words) ____________________________

Starting on (Day/Month/Year) _________________ and on the same day of each subsequent Month/Year thereafter, or immediately from the receipt of this order, whichever is the later, and until further notice.

My /our bank account number is __ __ __ __ __ __ __ __ __, and the 

sorting code number is __ __ - __ __ - __ __.  

Name(s) on cheque book_____________________________________________________.

Please pay Lloyds Bank, Weston-super-Mare - South Parade (Sorting Code 30-99-51) for the account of Weston Hospicecare Limited Collection Account, number 1383664.

Signed ________________________________ Please quote the reference: _____________________

Debit / Credit/ Charitycard Donations

Please debit my ________________________________ (Type of Card)

Name as on card _________________________________________

Card Number ____________________________________________

If Switch, please give issue Number _________.

Card Start Date (MM/YY) ________  Card Expiry Date (MM/YY) ________

Signature_____________________________ Date_______________

For card donations, please ensure that we have your full statement postal address

Please post this completed form to:
Weston Hospicecare Fundraising Department,
FREEPOST (SWB 502),
WESTON SUPER MARE,
BS23 4FA,
UNITED KINGDOM.