STANDING ORDER FORM
Please return to QVA at the above address, not to your bank

Bank name ………………………………………………………..…

Bank address ……………………………………………………….

……………………………………………………………………...…

Post Code ……………………………………………………….…..

A/c No. …………………………………………………………..…...

Sort Code …………………………………………………………….

Amount (circle) £5   £10  £15 £20  £……. 

First Payment  …./…./……..

And then (circle) monthly / quarterly / annually 

GIFT AID DECLARATION  (Please sign if you pay tax)
Please treat all donations I make to QVA from the date of this
declaration as Gift Aid donations. 

Signed ……………………………..Date …………………….

Instruction to the bank. 
Please pay the above to Triodos Bank 16-58-10  a/c 0329501 Quaker Voluntary Action 

Signed ………………………………………… Date ………………