Registration

NURTURING THE ROOTS OF SCOTTISH INDEPENDENCE

Customer Ref:

Schedule

Service/Schedule:

Termination:

Until further notice

Payment Information

Payment Day:

2019

First Payment Date:

01 December 2019

I wish to pay a regular Direct Debit of:

£5.00

Personal Details

Title

First name

Surname

Line1

Line2

Line3

Line4

Post code

Home phone number

Mobile phone number

Work phone number

Additional Information


1) How did you vote in the September 2014 Scottish Independence Referendum?:
2) Have you been involved in any pro independence activity like marches etc?:
3) Are you part of any pro independence groups? If YES, which one?:
4) Are you a member of any political party? If so, which one?:
5) How would you prefer to receive updates from SIF?:
6) How did you hear about us?:
7) What is your Date of Birth? (dd/mm/yyyy):

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

Eazy Collect Re Scottish Independe, 3rd Floor, Suite 1a, Sycamore House, 290 Bath Street, Glasgow, G2 4JR

Service User Number:

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.

Thank you for bringing independence closer by

supporting the overall grassroots movement through the

The Scottish Independence Foundation intend to invest £88,000 in this campaign to raise £528,000 over the next 2 years, £792,000 over 3 years or £1,056,000 if it takes 4 years to achieve Scottish FREEDOM