STANDING ORDER REQUEST FORM.
Please print off, complete in black ink and return to QVA (not to bank) so we can record all donations. Thanks.

To: Manager, Name of bank:………….....................….....……

Address of bank:………………………………………………………….…………………
Postcode: …………………………………….

Account No: ……………………  Bank Sort Code: …………………
I wish to make a regular payment by Banker’s Order to Quaker Voluntary Action.
Please set up a Standing Order to pay (please circle)

£3   £5   £10   £25   £35   £50   £…… each month/year (delete where applicable)
starting on …./…./….

Signed:……………………........ Date:…….. /……../……..

Name:…………………………………………….

Address: ……………………………………………………………………………………………

Postcode: …………………. Telephone:………………………..

Email:…………………………………….

Bank instruction: Please pay the above amount to Quaker Voluntary Action,
Triodos Bank, Brunel House, 11 The Promenade, Bristol BS8 3NN
Account Number: 03269501 Sort Code: 16-58-10 tel: 0117 973 9339

Gift Aid Declaration:
Please treat all donations I make to QVA from the date of this declaration, as Gift Aid donations.

Signed: .................................................Date:.............................

Return to:
1 Holt Lane, Holmfirth, West Yorkshire, HD9 3BW
E-mail: mail@qva.org.uk          
Charity Number: 1083412