Address …………………………………

Sort Code - - .

Please pay Lloyds Bank Sutton Coldfield Branch, Sort Code 30-98-37

for the credit of the British Homeopathic Dental Association,

Account Number 1582262.

The sum of £35.00 (thirty-five pounds) commencing immediately and thereafter annually on 23^rd April until further notice.

Please cancel any previous Standing Order in favour of the above named beneficiary

Please debit my/our account accordingly

ACCOUNT TO BE DEBITED……………………………………(Please print clearly)

NAME………………………………………...( Please print clearly).

Account Number………………………. Date…………………..