Barclays Bank Ltd, The Strand Longton S-O-T, ST3 2JJ Sort code

							                                LONGTON Rugby

                                 Supporter’s Club

                        Bank Standing Order Mandate

Bank Address       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx

Please debit my/our account no.       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Sort code     3       – 99      -      88

Quoting my reference         L LRUFC Supporter’s Club .

With £5.00 on the first day of each month.

Commencing        xxxxx/xxxxx/xxxx          Finishing   xxxxx/xxxxx/xxxx x




Name      dddddddddddddddddddd dxxxxxxxdddd

Address     dddddddddddddddddddddddddddddddddddd                 dxxxxxxxdd


Telephone No.         dd dxxxxxx                    xdddd


E Mail         dddddd dddd dxxxx                                    xxxdddd


Signature      dddddddddddddddddddd dxxxxxxxdddd