Old Lats Elite Club

Please print the form (click the print icon on your browser) and send it completed to Don Maughan at:

28, Crown St., Egham. Surrey. TW20 9BQ.

Name     ...............................................

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

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Tel Number         ....................  Mobile .................

E mail address     ...............................................

Bank ..............................................

Bank Address         ............................................................

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Sort Code    ....................... Account No. .......................

Instructions to the Bank.

Please arrange payment by direct debit the sum of £65 every three months on 1st April, 1st July, 1st October, 1st January every year starting on 1st April 2005 until further notice to the Old Latymerian Football Club, c/o Barclays Business Centre, Hounslow Branch, 210 High Street, Hounslow. Middx. TW3 1DL.

Sort Code 204676        Account No. 2  -  10334766

Signature  ......................................

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