Registration

Midlands Air Ambulance Charity, Hawthorn House, Dudley Road, Stourbridge, DY9 8BQ
UK Registered Charity Number 1143118

General Enquiries: [email protected]

Tel: 0800 8402040, Fax: 01384 486621

Customer Ref:

Schedule

Service/Schedule:

Termination:

Until further notice

Payment Information

Payment Day:

2024

First Payment Date:

15 May 2024

I wish to pay a regular Direct Debit of:

£1.00

Personal Details

Company name

Title

First name

Surname

Date of birth

Line1

Line2

Line3

Line4

Post code

Home phone number

Mobile phone number

Work phone number

Additional Information


How did you hear about us?: *
I would like to be kept informed about Midlands Air Ambulance Chairty projects and activities by email (we will not share your data and you can unsubscribe at any time): *

Instruction to your Bank or Building Society to pay by Direct Debit

Test SUN, Midlands Air Ambulance Charity, Hawthorn House, Dudley Road, Stourbridge, DY9 8BQ

Service User Number:

Custom Bank Reference:

Account holder name

Account number

Bank sort code

Please tick to confirm you are the only person required to sign for this account

Checking the box indicates that I am the Bank/Building Society holder and no authority other than my own is required. If more than one person is required to authorise debits from the account, you are unable to setup a direct debit online.