Afasic Standing Order Form

I would like to pay my membership subscription/make a donation* to Afasic by way of standing order.


To (bank name) __________________________________________

Of (bank address) ________________________________________

_____________________________________Post code _________

Account Number    _____________________


Please pay Afasic (please tick one)

each month
each quarter
each year

at Lloyds TSB Bank plc, Dartford Branch, 4 High Street, Dartford, Kent DA1 1BY. Bank Sort Code 30-92-53, Account Number 00843775, Account Name: Afasic.

The sum of £ _________________ Reference (leave blank) ___________

Starting on ___________________ Signed ________________________

Date ________________________

Your name: Mr/Mrs/Ms* _______________________________________

Address ____________________________________________________

_____________________________________Post Code _____________

* Please delete as appropriate in each case


Donation form

Gift Aid Declaration form


Thank you for your support.

Return to:
Afasic Cymru, Titan House, Cardiff Bay Business Centre, Lewis Road, Ocean Park, Cardiff CF24 5BS