RUSSIAN BLACK TERRIER CLUB (UK)  -  Annual Membership

 Regular Payments Form  Please tick relevant box

 SET UP A NEW STANDING ORDER.         and please complete all sections

Your Customer Account Details:

Account Name(s)________________________________________________________________

 Sort Code __   __   __   __  __  __    Account Number___________________________________

_______________________________________________________________________

 Section A  - Set up  a new Standing Order.

Beneficiary Details - (who you want to pay)

 Sort Code:   20 55 62           Beneficiary Name Russian Black Terrier Club(UK)

 Account Number 10 96 55 02

 Reference: rbtclub/ ___________________________________________________your full name(s)

 Amount of Annual Payment: Single £7.00p          OR   Joint £12.00p

 Frequency of Payment: ANNUALLY   Date of Payment   ______  January 2009  (1st -28th your choice)

 Please continue until further notice

_______________________________________________________________________

The relevant sections must be completed for your request to be processed.

ENSURE YOU SIGN AND DATE THIS FORM & POST or HAND IT IN TO YOUR OWN BANK.

(Where signing a mandate is ‘both or ‘all’; all relevant parties must sign to authorise.)

Customer Signature(s) _____________________________   _______________________________

 DATED __ __/ __ __/ __ __ __ __Customer Contact Telephone Number_____________________

 Note: to cancel a standing Order please inform your bank naming the Russian Black

Terrier Club - the amount, the payment date and the date when you wish to cancel.

 Members please could you also inform the RBT Club Membership Secretary you have

chosen to pay by standing order; Mrs Linda Searson. 26, Osprey Drive, Netherton,

Huddersfield HD4 7LG   Tel: 01484 666 897    E-mail:duke8@tiscali.co.uk

                                                                                                                          November 2008