Bankers Order Form

To the Manager¹   ........................................................................
Address   ....................................................................................
....................................................................................................
Postcode   ...................................................................................

Please pay to Clydesdale Bank,
University of Glasgow Branch, 326 Byres Road, Glasgow G12 8AN
for the account of the St Andrew's Clinics for Children,
Account No 40300586
starting on the ........... day of ............................... month²
and on the same day of the month/year³ until further notice,
the sum of:

...........................................(words)⁴ , .......................(figures)⁴

from my Account Number  ..................................

Sort Code  .....................................

Signed ............................................

Address  .......................................................................................
               .......................................................................................
Postcode ..............................
Date  ....................................

Notes
1   Please enter the details of your own Bank.
2   Please enter the date when your first payment is due. This date must be after the signature date.
3   Delete as appropriate.
4   Please enter the actual amount you wish to give in words and figures.

When completed and signed, please return the Bankers Order Form to:
St Andrew's Clinics for Children, PO Box 461, Glasgow G12 8QT