Please print off this form, complete the details of your bank and yourself, and return it duly signed to: The BSA, 15 Old Ford Road, London E2 9PJ. Please do not send the form to your bank.

To the Manager of your bank:

Name and address of bank:...................................................................................................

................................................................................ Postcode:...........................

Account No.: ........................................ Sortcode:................................................

Please pay to CafBank Ltd (40-52-40), Kings Hill, West Malling, Kent, ME19 4TA, for the credit of the British Stammering Association (Account No. 00008336)

the sum of* ........................................................................................................
(figures, then words)

starting immediately on receipt of this order, and thereafter the like sum on the 6th day of June of the following years until this order is cancelled in writing.

Name and address:...............................................................................................

................................................................................ Postcode:............................

Signature:...............................................Date...........................

*The sum is your annual subscription (£15, or £5 concessions), plus any further annual amount you would like to donate.