PAYROLL GIVING DONATION FORM
  
PLEASE PRINT OUT AND COMPLETE THIS FORM IN BLOCK CAPITALS

SURNAME:

FORENAMES:
HOME ADDRESS:


POST CODE:
   TITLE: MR / MRS / MISS / MS
(Delete as appropriate)
TELEPHONE NO:   HOME
N.I. NUMBER (If known):
EMPLOYER'S NAME:
JOB TITLE:
WORK
EMPLOYEE / STAFF NO:
LOCATION (Town):
DEPARTMENT:

AGE (please tick box): 16-25 [    ]      26-35 [    ]      36-45 [    ]      46-55 [    ]      56 + [    ]

WE NEED TO KNOW THE FOLLOWING:

Name & address (if known)
of the Charity(ies) you wish to support.

 

How much do you wish to give?

(You could put the name of your charity
here if you wish)

 

£               :          p

£               :          p

£               :          p

£               :          p

TOTAL  

£               :          p

Per Month / Week or Other (please specify):
Are you an existing Payroll Giver?    YES / NO
SIGNED:                                              DATE:
The data supplied on this form will be used to enable your donations to reach your chosen charity/charities.
In order that your instructions can be acted on, your details will be passed to Her Majesty's Revenue & Customs registered Agency, with whom your employer has contracted, who will forward your donations to your chosen charity/charities.   
Your chosen charity/charities may send you a thank you letter acknowledging your donation.
If you do not wish to receive acknowledgement from your charity and only wish to be contacted in the event of a specific query needed to resolve the processing of your data for the purposes of these instructions, please tick here. [    ]