Nottingham Civic Society

To: ............................................................................................................................... Bank / Building Society

Branch address: .................................................................................................................................................

Pay immediately on receipt of this form and thereafter annually on the first day of January until further
notice the sum of £.......................................................................... [amount in words]

To: National Westminster Bank plc, Nottingham City, 148-149 Victoria Centre, Nottingham NG1 3QT

Sort code: 60 80 09

For the credit of: Nottingham Civic Society

Account no.: 88899659

Signed: .................................................................................. [your signature]

Name: .............................................................................................................. [name(s) in which your account is held]

Address: ......................................................................................................................................... [your address]

Date: ................................................