Instruction To Your Bank Or Building Society To Pay By Direct Debit (Page 2 of 2) in pdf

Research Autism Friendship Form - organisations

Please complete and return this form to Research Autism with a cheque, postal order or your debit/credit card details.

1. Tell us about yourself

Organisation name

Address

Postcode

Country

Nominated staff member’s name

Title

First name

Surname

Staff member’s job title

Telephone No

Nominated staff member’s email

Preferred email Format

HTML (with graphics)

Plain text

2. Please tell us about your organisation’s connection to autism:

Research body

Policy Making/Campaigning body

Other (please specify below):

Education Provider

Health/Social Care Provider

3. Tell us what you would like your nominated staff member to receive:

Weekly email news bulletin on autism from around the world

Monthly email news bulletin on autism research from around the world

Regular email updates on the work of Research Autism inc. our newsletter

Presentations from Research Autism conferences and other events

Discount on delegate rates at Research Autism conferences and events

4. Privacy statement:

Please tick this box to indicate that you understand that Research Autism will store the information you have

provided securely for the purposes of administrating your membership of this Friendship scheme.

Research Autism would like to update you from time to time in order to inform you about our work.

If you do not wish to receive any mailings from Research Autism please tick this box.

5. Tell us how much you wish to pay

(please see page one for annual contribution rates)

We wish to make a one-off payment for one year:

We wish to set up a direct debit to make an annual contribution of:

We wish to set up a direct debit to make a monthly contribution of:

We wish to add a one-off contribution of:

6. Choose your payment method

Direct Debit Please complete the Direct Debit form on page one of this leaflet. If you pay by Direct Debit

payments will be taken at the interval and amount that you have indicated you wish to pay in the table above.

Cheque/Postal order – payment for one year

Please make your cheque or postal order payable to Research Autism and send it with this form to Research

Autism, Adam House, 1 Fitzroy Square, London W1T 5HE.

Invoice (payment for one year)

Please provide a requisition number if your organisation requires this:

Address to send invoice to

(if different from above)

Credit/Debit card (payment for one year). Please complete the details below:

I wish to pay using my Mastercard/Visa/Maestro card/Solo/American Express card

Card holder’s name:

Card Number:

Security No

Issue No

Start date

Expiry date

7. Please return this form to: Research Autism,

Adam House, 1Fitzroy Square, London W1T 5HE.

For Research Autism office use only: Membership Type: ________________ Membership No: _________________ Renewal Date: __________________

Instruction To Your Bank Or Building Society To Pay By Direct Debit Page 2

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