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Please print out the form below and return completed and signed to; EKPCA, Maidstone Masonic Centre, Tovil, Maidstone, Kent. ME15 6QS Telephone: 01622 766212. Email:
I instruct you, in accordance with the currently published Rules of the Association,
to take £ : from my/our account with the Association and donate it to:
(Please tick your choice. If more than one is indicated donations will be divided equally)
Charity
Address............................................
2. Surname .. .. First Names ......... .... ...
Address . ...
. . . Post Code .. ..
Tel. No. .. Email........................................................................................................................................
Date of Birth ./ . ./ . .
Credit to Lodge Name & No. .
3. On behalf of .. Date of Birth .../ .. ./ .. .
4. Signed .. .. .. Signed . .. . .. Date ...
Data Protection Act: If you do not agree to the
details of your account with the Association being made available to your
Lodge Charity Steward, please tick :
------------------------------------------------------------------------------------------------------------------------------------------------------ See notes below:
1. Tick one or more boxes in Section 1. When more than one box is ticked the donation will be divided equally between the charities indicated. If the choice is to a charity other than the selection provided, enter the full name and address of the charity in the section provided below. The choice must be to a recognised charity or charitable cause; only Premium 'A' Members (e.g. Lodges) can donate directly to individuals. Instructions given are irrevocable. 2. Complete Section 2 in every case. Use 'Day, Month, Year' format for the date of birth, which is essential for positive identification. If you are (a) the nominated representative of a Premium 'A' Member or (b) the sponsor of a 'Junior' under the age of 16, you should complete this section and the On behalf of . In Section 3. If the donation is to be credited to a Lodge, Chapter or Order total for an appeal or Festival, add the number of the Lodge or Chapter or the name of the Order at Credit to Lodge .. 3. Only complete the On behalf of in Section 3 if the donation is from a Premium 'A' Member or a Junior under the age of 16. Enter the Junior's date of birth in 'Day, Month, Year' format. 4. Single signatures are required from Ordinary Members who sign on their own behalf or on behalf of Junior Members under the age of 16. Two signatures are required from Premium 'A' Members - the nominated representative together with another Lodge or Club official. Please indicate the office held by each signatory.
East Kent Provincial Charities Association is a Registered Charity No. 1023859
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