STANDING ORDER

To: _______________________

Bank ______________________

Branch: Please pay 01-00-04

National Westminster Bank plc

Accrington Branch

A/C Name: Hyndburn Stray Dogs in Need

A/C No: 15461149

First payment: £__________ on _____________ (date)

Future payments: £________ monthly on the __________(day of the month)

Date of last payment _______________________

Please charge such payments to my/our account No: ____________________

Signature 1________________________ Print________________________

Signature 2 _______________________ Print ________________________

Date: ___________________