Regular standing order form

Please print and complete the form below and post it to Madina Masjid 4/8 Forest Street, Nelson BB9 7TX UK. Once we have received the completed form we will keep a photocopy and send the original one to your bank so that they can process payments.

Your name & address: ..........................................................................

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

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

Your bank:
To: ........................................................................................................
(Bank/Building Society)

Bank's address: ....................................................................................

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

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

Your account:
Account no: ......................................... Sort code: ................................

Please pay to Lloyds TSB Bank of Church Street, Blackburn, Lancashire, BB2 1JQ for the account of The Madina Masjid (Account No. 00117403) (Sort Code 30-90-87):

Amount (in words & figures):

The sum of £ ............................. (figures) ..............................................

................................................................................................(words)

on the .........................day of............................(month).......................(year)

and a like sum each month until further notice.

Signature:
Date:

PLEASE NOTE THAT THIS REPLACES ANY PREVIOUS STANDING ORDER FORMS