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
2025
First Payment Date:
15 January 2025
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.