Country Doctors Association - Standing Order Form
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To the Bank Manager, Bank

Address
Postcode
 

Please Pay £30/20* immediately and the same sum each year on January 1st until further notice debiting my account number

in favour of the Country Doctors Association, Midland Bank, Market Square, Hinckley, Leics, Code 40-24-19 Account Number 11395467.

* delete as appropriate
Name
Account Name
Home Address
 
 
 
Postcode

Signed ___________________________      Date ____________________________   

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