Cardiff Cycling Campaign


To the Manager
Name of bank __________________________Name of A/C: _______________________
Address of bank ________________________Sort Code: ______________________
_____________________________________Account Number _____________________

Please pay the following Annual amount of

2.50 4.00 5.00 6.50
(unwaged individual) (unwaged joint) (waged individual) (waged joint)

and a donation of

Annual Total:

starting on the 20th day of __________ [month] until further notice,
debiting my account to
    Cardiff Cycling Campaign, A/C 61074261, HSBC, Sort Code 40-16-17, Rumney, Cardiff, CF3 4FH,
quoting reference no:
                 (to be inserted by Cardiff Cycling Campaign)

Signature ________________________________
Date ______________