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Glencairn Memorial Institute

Chapel St., Moniaive, DG3 4HP. Scottish Charity No. 009179

To your bank manager:

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Your Name *

First

Last

Your Address (incl. post code) and email/phone *

Please pay until further notice:

Commencing immediately and repeating ANNUALLY, the sum of:

Select One *

From my account with details below:

Bank Name, Account Name, Number, and Sort Code, *

Date *

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