Registration

Company No: 02053063

Charity No: 295198

Address: Unit 31 Park Fam Ind Estate, Buntingford, Herts, SG9 9AZ

Phone: 01603 406767

Email: [email protected]

Customer Ref:

Schedule

Service/Schedule:

Termination:

Until further notice

Payment Information

Payment Day:

2024

First Payment Date:

01 May 2024

I wish to pay a regular Direct Debit of:

£25.00

Personal Details

Title

First name

Surname

Date of birth

Line1

Line2

Line3

Line4

Post code

Home phone number

Mobile phone number

Work phone number

Additional Information


1. Membership Type: *
2. Group Name (if applicable): *

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

Eazy Collect Re National Womens, First Floor, Unit 31 Park Farm, Ermine Street, Buntingford, SG9 9AZ

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.