Registration

Eden Valley Hospice, Durdar, Carlisle, CA2 4SD

Telephone: 01228 810801 Email: care@edenvalleyhospice.org

We couldn't provide our care to local adults and children without your overwhelming kindness and support.

Customer Ref:

Schedule

Service/Schedule:

Termination:

Until further notice

Payment Information

Payment Day:

2019

First Payment Date:

15 February 2019

I wish to pay a regular Direct Debit of:

Personal Details

Title

First name

Surname

Line1

Line2

Line3

Line4

Post code

Home phone number

Mobile phone number

Work phone number

Additional Information


1. Reason for donation:
2. Would you like to receive our Newsletter?:
3. Would you like to hear about our Events and Appeals?:
4. Would you like to hear about our Weekly Lottery?:
5. Would you like to receive our Raffle Tickets?:
6. Would you like information about our Hospice Shops?:
7. Would you like details about Volunteering at the Hospice?:

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

Eden Valley Hospice Carlisle, Durdar Road, Carlisle, CA2 4SD

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. Please download PDF version of direct debit instructions by clicking on the button below.