Society of Manchester Dental Alumni
Membership form / Standing Order
Membership fees are only £20 per year. Please complete the details below and return the whole form
to:
Mr Nick Ward, Membership Secretary
5 Wensley Road, Cheadle, Cheshire. SK8 9PL
Name
Address
Post code
E-mail
Address
@
Standing order
To The Manager
Your bank
Address
Post code
Please make the payments detailed below and debit my/our account
Your account Name
Your account Number
Bank sort code
Reference no. (to be
completed by the
Membership Secretary
Name of payee
Account number
Address of payee
Bank and Branch
Code number
Amount
Date of First Payment
Manchester Dental Alumnus Society
(Society of Manchester Dental Alumni)
12672723
University Dental Hospital of Manchester,
Higher Cambridge Street, Manchester M15 6FH
The Royal Bank of Scotland plc
Manchester University Branch
Precinct Centre, Oxford Road
Manchester.
16-25-14
£20.00 (twenty pounds) immediately and then £20.00 (twenty
pounds) annually commencing 6th April 2015.
£20.00 immediately and £20.00 annually on 6th April (commencing
2015)
Payments are to continue until you receive further notice in writing. This instruction cancels any
previous order in favour of the payee named above or under this reference
Signature
Date