IMO Form by 98w4iY


									In memory gift form
Losing someone close to you is one of the hardest experiences to go
through. Often there is a need to recognise and celebrate the life of that
person, in a way that is fitting and meaningful.

 Title                       Name


 Postcode                         Tel. No.


 My donation is in memory of:

 to the

I enclose a cheque payable to BUI for £

 Or please debit my Mastercard/Visa/Maestro/Solo (please circle) for the amount £

 Card No.                                                                                          Maestro only

 Start                           Expiry                        Security No.                   Issue
 date                            date                          (last 3 digits on              No.
                                                               reverse of card)

 Signature                                                                         Date

                                     I would like to Gift Aid all donations that I have made to BUI within the
                                     last 6 years and all future gifts, until further notice. I confirm that I pay
                                     sufficient UK income/capital gains tax to cover any tax that BUI will reclaim
                                     from any donations that I make. Please let us know if your tax status or
                                     personal details change. We can claim back an extra 28p from the HM
                                     Revenue & Customs from every £1 you give us at no cost to you.

Signature                                                                Date

Your generosity will help us ensure that we can continue to fund much needed research. Thank you very
much for your donation, please send your form and donation to:
            Bristol Urological Institute | Southmead Hospital | Bristol | BS10 5NB | UK

         BUI may contact in the future about our work. If you prefer not to be contacted please tick box

               T: +44 (0)117 323 5690 | F: +44 (0)117 323 8830 | E: |
                                         Charity Registration No. 1055900

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