Fill in the form below, then print it out and send it with your application form to Mrs. B. Walker at the address above.

Super 100 Heritage Club Standing Order

To: Bank Plc /Building Society
Address:
Postal Code:
Please pay to: The Dacorum Heritage Trust Limited 'Super 100 Heritage Club' Lloyds TSB, 198-200 Marlowes, Hemel Hempstead HP1 1BH Sorting code: 30-94-08 Account number: 02900696
The sum of:
Commencing on the first day of:	Month  Year ..... and annually thereafter
Name of account to be debited:
Account Number:
Member's name:
Member's Address:
Postal Code:
Telephone:
Signature: ..................................................    Date: ...................

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