Your bank and account details:
Account name:
Bank name:
Address:
Sort code:
Account no:
Please pay £ Once only Weekly Monthly Quarterly Annually from my bank account (details above) to:
HSBC Bank plc, 6 Old Church Road, Clevedon, North Somerset BS21 6NA
Account name:	PCC Clevedon St. Andrew
Sort code:	40-17-50
Account number:	91321234
Signed:
Date:

Please sign, date and return this form to your bank.

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