Please use BLOCK CAPITALS when filling in this form.

Please return the completed form to the Waterford Healing Arts Trust, not directly to your bank.

Thank you for taking the time to become acquainted with our work.

Waterford Healing Arts Trust, Waterford Regional Hospital, Dunmore Road, Waterford,

T 00353 (0)51 842664, F 00353 (0)51 848572

Bank details

To:

The Manager

Name of your bank

Address of your bank

Your details

I / We (name)

authorise and request you to debit my / our Account no:

and credit the account of

Waterford Healing Arts Trust,

Account number 12555094

AIB Bank, Ardkeen Branch, Dumore Road, Waterford,

Sort code 93 44 02

with the sum of €

(amount in words)

The amount is to be paid

(annually, quarterly, monthly)

for a period of

years, that is a total of

payments.

The first payment is to be made on

It shall be understood that the Bank shall not be under any liability for damage or loss caused by any omission to make these payments. Please allow at least five working days notice prior to the date of the first payment.

Signature (s)

Date