REF.

(A) WITHDRAWAL INSTRUCTIONS

To:   The Manager:.................................................................. (Bank's name)

        Branch        ...................................................................

        Address      ..................................................................................................................
 

My account number

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Bank Sort Code

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You are authorised to set up a Standing Order on my/our account and debit the amount specified below on an annual basis until further notice in writing from the date indicated below.

Amount    €........................    IN WORDS .................................................................................

Signed.................................................................

Signed................................................................. (Joint account holder)

Date....................................................................

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(B) PAYMENT INSTRUCTION               PAYEE DETAILS

Name on account:                Countryside Ireland
Name of Bank & Branch:       Bank of Ireland, Greystones, Co Wicklow.
Bank Sort Code:                   90-11-32
Account Number:                  14210930

Start Date:

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D

D

M

M

Y

Y

Y

Y

Frequency:                           Annual.

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FOR OFFICE USE ONLY:                                            BRANCH STAMP