Direct Debit

Direct Debit

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Your donation

I would like to give: * £ a month

Starting on: *

1st September 2010

15th September 2010

When would you like your direct debit to start?

Contact details

Title: *

Title (if other):

Firstname: *

Surname: *

Post Code: *

Address: *

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County: *

If you are outside of the UK or do not have a county, you may leave this field blank.

Email: *

Yes I would like to receive your bi-monthly enewsletter with news of upcoming events and your breaking research?

Phone number: *

If the post code lookup doesn't work for your post code, please enter your address manually.

Bank/building society details

Bank/building society name: *

Account holder name: *

Account number: *

Sort Code: *

Enter the sort code in the format 00-00-00

In order to set up a Direct Debit online you need to confirm the following:

By ticking this box I confirm that I am the named account holder of the account to be debited

Does this replace an existing instruction?: *

Yes

Are you a UK tax payer?

Find out more about Gift Aid

I am a UK taxpayer and I would like Action Medical Research to reclaim the tax on all donations I have made as well as any future donations.

Please note: You must pay an amount of Income Tax and/or Capital Gains Tax at least equal to the tax that the charity reclaims on your donations in the appropriate tax year (currently 25p for each £1 you give).

I am a UK tax payer and wish to claim gift aid on my donation

Action Medical Research

the charity saving and changing children's lives

Your donation

Contact details

Bank/building society details

In order to set up a Direct Debit online you need to confirm the following:

Are you a UK tax payer?

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