STANDING ORDER FORM

To___________________________________ Bank
(fill in the name of your bank)

Your sort code number ___________

Address of your bank __________________________________________________________

Please make payments and debit my/our account number ___________________________

in accordance with the following details:

Pay the
CO-OPERATIVE BANK P.L.C.,
195 High Road,
Wood Green,
London, N22 6DP

for the account of Haringey Solidarity Group, Centre Account
(Account number 50058426 and Sorting Code number 08-90-37)

the sum of £ ______________________ payments to be made weekly/monthly (delete one) until further notice by me/us.

Payment to start on the __________ day of ____________ 20_____

Signature ________________________________________

Date _______________________

Return this form to H.S.G. at P.O. Box 2474 London N8, NOT your bank - thanks