Bankers Order Form

To.................................................................................Bank

..................................................................................Branch

Address..................................................................................

.............................................................................................

Sort Code………/………/……...

Please pay on……………………………………..(date of first payment)

to National Westminster Bank plc, Street Branch (Sort Code 60-21-01) the sum of

£5 (five pounds) Ordinary Member
£7.50 (seven pounds and fifty pence) Family Member (please delete as appropriate)

For credit to the account of Glastonbury Antiquarian Society (account no, 51035367) and next on

1st September 2008 and thereafter annually on 1st September each year until further notice,

charging such payments to

my………………………………... Account, numbered…………………….

THIS CANCELS ANY EXISTING ORDER IN FAVOUR OF GLASTONBURY ANTIQUARIAN SOCIETY

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

Date..........................................

Member's Name (please print)………...........................................................................

For completion by GAS Office : Society Reference Number......................................

This form should be sent with the Application Form to the Membership Secretary:

Mrs Dawn Bonham, Glastonbury Antiquarian Society, 53 Hill Head, GASTONBURY, BA6 8AW

Glastonbury Antiquarian Society, 48 High Street, Glastonbury, Somerset BA6 9DX - Registered Charity No: 309955
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