Customer Ref:
Schedule
Service/Schedule:
Service - Standard DD Schedule - Rolling
Termination:
Until further notice
Payment Information
Payment Day:
1
15
January
February
March
April
May
June
July
August
September
October
November
December
2024
First Payment Date:
01 October 2024
I wish to pay a regular Direct Debit of:
£
Personal Details
Title
---Select---
Mrs
Mr
Miss
Ms
Dr
Sir
Lord
Lady
Prof.
Rev.
Master
Mx
---Other---
First name
Surname
Date of birth
Line1
Line2
Line3
Line4
Post code
Home phone number
Mobile phone number
Work phone number
Email
Additional Information
1. I confirm I am at least 16 years or over:
---Select---
Yes
No
2a. How did you hear about us?:
---Select---
Friend/family
Local press
Website
Social media
Other
2b. If "Other", please specify:
3. Who referred you to us?:
---Select---
OLLIE PARDO
AGENT
COMMUNITY T
4. Are you a season ticket holder?:
---Select---
Yes
No
5. DATA PROTECTION:
---Select---
Yes you can contact me
No you can't contact me
Instruction to your Bank or Building Society to pay by Direct Debit
CFC 2001 Limited, The Smh Group Stadium, 1866 Sheffield Road, Chesterfield, S41 8NZ
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.