Standing Order Form Wizard | x2y LGBTQ+ Youthgroup Wolverhampton

Your Name

Your Email (required)

Your Telpehone Number (required)

Please Enter Your Bank Details (required)
NAME OF BANK (required)

NAME OF CARDHOLDER (required)

ACCOUNT DETAILS (required)

Please Enter Your Bank Details (required)

PLEASE SELECT THE AMOUNT YOU WISH TO DONATE MONTHLY (required)
£1£3£5£10£15£20
OR ALTERNATIVELY, PLEASE ENTER A DIFFERENT AMOUNT YOU WISH TO DONATE
PLEASE SELECT THE AMOUNT YOU WISH TO DONATE MONTHLY

PLEASE SELECT THE DATE YOU WISH THE DEBIT TO COMMENCE FROM:

As confirmation, please write IN WORDS the amount you wish to donate via standing order (required)

PLEASE ENTER ANY ADDTIONAL INFORMATION HERE - THIS IS OPTIONAL

To Summarise:

Name: [answer "your-name"]

Your Email: [answer "your-email"]

Your Telephone Number: [answer "tel-242"]

Name on Card: [answer "text-476"]

Name of Bank: [answer "textarea-175"]

Sort Code: [answer "number-950"]

Account Number: [answer "number-12"]

Amount to Debit: [answer "checkbox-28"]

Start Date: [answer "date-137"]

Additional Information: [answer "textarea-554"]

I CONFIRM THESE DETAILS ARE CORRECT. PLEASE CONFIRM BY CHECKING THE BOX (required)

The information is correct

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