TO (Name of Bank)………………………………………………….
     (Branch address)…………………………………………………
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Please make payments to and debit my account No. ……………………
in accordance with the following details :-

National Westminster Bank Plc.
Seven Kings Branch,
643 High Road,
ILFORD,
Essex.
IG3 8EH

Sort Code No.   60 19 01
For the account of The Falconer Trust
Account No.   40102858
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£  ...............................
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Payments to be made monthly/quarterly/annually  (delete as appropriate)

Date of first payment  …………………………………………………….

Date of final payment (or until further notice) ……………………………

Signed ………………………………

Address ………………………………………………………
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Date………………………………………………………….