registered charity 1052989
Full Name:…………………………………………………………………………………………………
Address:……………………………………………………………………………………………………
…………………………………………………………………Postcode ……………………………….
Tel:(Day).……………………………………… …Tel:(Evening)……………… …………………………
Email: …………………………………………………… Fax :………… ………………………………
ANNUAL SUBSCRIPTION (please select from the options below):
| Single payment |
Recurring Annual Donation |
_• UK £25 (cheque/card) |
_• £20 (standing order/card) |
_• Overseas £35 (cheque/card) _• Student/Unwaged: One year: UK £5 (Please provide copy of NUS card/income support information) |
| GIFT AID DECLARATION: I am a UK taxpayer and I
would like the DRT to treat my Member’s subscription as Gift Aid and
all further donations I make from the date of this declaration until I notify
you otherwise.
Signed………………………………………………………… Date of declaration …………………………………… |
- CHEQUES/POSTAL ORDERS (£ sterling cheques only, payable to the Dyslexia Research Trust)
- VISA / MASTERCARD / SWITCH (Please circle your choice. We
regret that other cards cannot be accepted)
Cardholder’s name:………………………………………………………………………………...........
Credit/Debit Card no:…………………………………………………...
Expiry date: …………………
Signature: ……………………………………………………………… Date …………………………
Please debit my card with the sum(s) I have authorised above
To the Manager (Bank Name & Address) …………………………………………………………………………………………………
Bank Sort Code …………/…………/………… Account Number……………………………………………………………………….
Account Name …………………………………………………………………
DRT Ref:(Office use only – leave blank)
Please make an immediate payment of: £20 (twenty pounds) followed by
annual payments of the same amount, commencing twelve months from this date
until further notice from me, to:
The Co-operative Bank,
13 New Road,
Oxford
OX1 1LG.
Sort Code 08-90-38, A/C No. 50063055, credit of the Dyslexia Research Trust
Signature ……………………………………………………………………
Dated …………………………………………………………….................
* IMPORTANT: Please return this form to the Dyslexia
Research Trust. (Do NOT send it directly to your
bank)