Subscription Form

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Instruction to your bank or building society
to pay by Direct Debit
Please fill in this form and send to: Research Autism, Adam House,
1 Fitzroy Square, London W1T 5HE
Name and full postal address of your bank and building society
To the Manager of
Bank/building society:
Address:
Postcode:
Name(s) of account holders:
Branch sort code:
Bank/building society account number:
Service user number:
7
5
6
4
7
5
Reference:
Friends of Research Autism
Instruction to your bank or building society
Please pay the National Autistic Society Direct Debits from the
account detailed in this instruction subject to the safeguards assured
by the Direct Debit Guarantee. I understand that this instruction may
remain with the National Autistic Society and, if so, details will be
pass electronically to my bank/building society.
Signature(s)
Date
Banks and building societies may not accept Direct Debit instructions for some types of account.
This Guarantee should be detached and retained by the payer.
The Direct Debit Guarantee
 This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
 If there are any changes to the amount, date or frequency of your Direct Debit the National Autistic Society will notify you 10 working
days in advance of your account being debited or as otherwise agreed. If you request the National Autistic Society to collect a payment,
confirmation of the amount and date will be given to you at the time of the request
 If an error is made in the payment of your Direct Debit, by the National Autistic Society or your bank or building society, you are entitled
to a full and immediate refund of the amount paid from your bank or building society.
 If you receive a refund you are not entitled to, you must pay it back when the National Autistic Society asks you to
 You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required.
Please also notify us.
Become a friend of Research Autism
Research Autism is the only UK charity exclusively dedicated to
research into interventions in autism.
About our new Friends scheme
By becoming a Friend, you can help us to transform the lives of people with autism now and in the
future by making a regular financial contribution towards our work. As a Friend, you will have
access to:
• Regular weekly and monthly bulletins on the latest news and research from around the world,
delivered straight to your inbox
• Discounts on delegate rates for Research Autism conferences, which address the latest thinking
in autism
• Free online access to presentations from our conferences from renowned speakers. Previous
conference speakers have included Professor Simon Baron-Cohen, Professor Christopher
Gilberg, Dr Lorna Wing and others.
Our aim is to develop the scheme further over the coming months by adding additional services, so watch this space
for more news. Sign up now and become a founder member of our Friends scheme.
Friends’ minimum annual contribution rates:
UK based individuals: £24
UK concessionary rates (students, on benefits): £12
Overseas based individuals: £36
Organisations: please contact us for details
“I provide medico-legal reports for courts and am required to proffer my
professional opinion in respect of provision and interventions for children and
young people with autism. Being a Friend of Research Autism keeps me up to
date with the current level of evidence secured for various approaches.”
Dr Hilary Dyer, MBPsS, FRSA, Consultant Educational Psychologist,
Specialist in Neurotypical and Neurodevelopmental Disorders
Sign up online at www.researchautism.net/friends or complete the friendship form overleaf
Please note that in order to keep expenditure to a minimum, some direct debits are collected on our behalf by the National Autistic Society
Research Autism, Adam House, 1 Fitzroy Square, London W1T 5HE
Tel: 020 3490 3091; Email: info[email protected]; Registered Charity No: 1096508
Research Autism Friendship Form
Please complete and return this form to Research Autism with a cheque, postal order or your debit/credit card details.
1. Tell us about yourself
Title
Surname
Address
Postcode/Zip code
Country
Email address:
Email format:
Forename/s
HTML (with graphics)
Plain text
2. If you are happy to, please tell us about your connection to autism:
Person with autism
Parent or Carer
Researcher
Education Provider
Health/Social Care Provider
Policy Maker/Campaigner
Other (please specify below):
3. Tell us what you would like to receive
Weekly email news bulletin on autism from around the world
Monthly email news bulletin on autism research from around the world
Regular email updates on the work of Research Autism inc. our newsletter
Presentations from Research Autism conferences and other events
Discount on delegate rates at Research Autism conferences and events
4. Privacy statement:
Please tick this box to indicate that you understand that Research Autism will store the information you have
provided securely for the purposes of administrating your membership of this Friendship scheme.
5. Tell us how much you wish to pay
I wish to make a one-off payment for one year:
I wish to set up a direct debit to make an annual contribution of:
I wish to set up a direct debit to make a monthly contribution of:
I wish to add a one-off contribution of:
£
£
£
£
6. Choose your payment method
Direct Debit Please complete the Direct Debit form on page one of this leaflet. If you pay by Direct Debit
payments will be taken at the interval and amount that you have indicated you wish to pay in the table above.
Cheque/Postal order – payment for one year
Please make your cheque or postal order payable to Research Autism and send it with this form to Research
Autism, Adam House, 1 Fitzroy Square, London W1T 5HE.
Credit/Debit card (payment for one year). Please complete the details below:
I wish to pay using my Mastercard/Visa/Maestro card/Solo/American Express card
Card holder’s name:
Card Number:
Security No
Issue No
Start date
Expiry date
7. Giftaid it
Using Gift Aid means that for every £1 you give, we get an extra 25p from HMRC (or 28p for each £1 of donations up to
5/4/08) So if you want your support to go further please Gift Aid it. Just tick the box – it’s that simple. (To qualify for Gift
Aid, what you pay in UK income tax and/or capital gains tax must cover the amount we will reclaim in that tax year.
Other taxes such as VAT and Council Tax do not qualify.)
Please treat as Gift Aid donations all qualifying gifts of money made (Tick all boxes you wish to apply):
Today
In the past 4 years
In the future.
8. Please return this form to: Research Autism, Adam House, 1Fitzroy Square, London W1T 5HE.
For Research Autism office use only: Membership Type: ________________ Membership No: _________________ Renewal Date: __________________