Registration

11 Greenvale Road Eltham, London SE9 1PB

Registered Charity No. 1166920

Telephone: 020 3732 6359 Email: [email protected]

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

Title

First name

Surname

Line1

Line2

Line3

Line4

Post code

Home phone number

Mobile phone number

Work phone number

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

APS Re Good Life, 11 Greenvale Road, Eltham, London, SE9 1PB

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.

You can cancel your monthly donation subscription at any time. There is no contractual obligation to remain for a period of time. Termination will take effect immediately although any funds which have been collected at the point of termination are non-refundable.

Click here to print Direct Debit form