Customer Ref:
Schedule
Service/Schedule:
Gym only off-peak+ - 12 Month Gym Only Off-Peak+
Gym only off-peak+ - 6 Month Gym Only Off-Peak+
Termination:
Take certain number of debits
Number of Debits:
12
Payment Information
Payment Day:
1
15
January
February
March
April
May
June
July
August
September
October
November
December
2025
First Payment Date:
15 July 2025
I wish to pay a regular Direct Debit of:
£25.00
Personal Details
Title
---Select---
Mrs
Mr
Miss
Ms
Dr
Sir
Lord
Lady
Prof.
Rev.
Master
Mx
---Other---
First name
Surname
*
Line1
Line2
Line3
Line4
Post code
Home phone number
Mobile phone number
Work phone number
Email
*
Instruction to your Bank or Building Society to pay by Direct Debit
APS Re Lighthouse Dental, Ladywell Annexe, Ladywell, Dover, CT16 1DG
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.