| Date | ...................................................... |
| To (Bank Name) | ...................................................... |
| Address | ...................................................... |
| ...................................................... | |
| ...................................................... | |
| Bank Account Number | ...................................................... |
| Please pay the sum of | £..................................................... |
| in words | ...................................................... |
| To Barclays PO Box 96, Ilford, Essex IG2 6BU | |
| For the credit of Hopefield Animal Sanctuary | |
| Sort Code (To be completed by Hopefield Animal Sanctuary) | |
| Account Number (To be completed by Hopefield Animal Sanctuary) | |
| On the ............ day of .................................. 2009 | |
| and on the same day annually/monthly/weekly until further notice charging my account. | |
| Signature | ...................................................... |
| Full Name | ...................................................... |
| Address | ...................................................... |
| ...................................................... | |
| ...................................................... | |