LONDON IRISH – 200 CLUB APPLICATION FORM

Please print, complete, sign and send the Banker’s Order to The Hon. Secretary who will forward it to your bank, retaining a copy for his records. Your ‘code letters’ will be notified to you at the same time, making you eligible for the next score prize.

Send the form to:

Jimmy Reilly,
LONDON IRISH AMATEUR RFC
47 Poulett Gardens
TWICKENHAM
Middlesex, TW1 4QS
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LONDON IRISH RUGBY FOOTBALL CLUB: THE 200 CLUB

   BANKER’S ORDER

To:
THE MANAGER:
________________________________________ BANK
ADDRESS:

___________________________________________________

___________________________________________________

SORT CODE:

______ - ______ - _____


Please pay - until further notice - to:
THE ROYAL BANK OF SCOTLAND PLC (16-00-53)
127/128 High Holborn
LONDON, WC1V 6PQ
for the credit of:
LONDON IRISH RUGBY FOOTBALL CLUB
No. 3 Account – Account No: 12509395

the sum of twelve pounds (£12.00) on receipt of this order AND THEREAFTER THE SAME AMOUNT ON THE FIRST DAY OF THE SAME MONTH ANNUALLY.

Please debit my account with the same.
      NAME (block letters):
__________________________________________________________
      ADDRESS:

__________________________________________________________
__________________________________________________________
      Account No:
_____________________________
      Signature:
_____________________________
Date: ____________________
      Tel.No(Home):
_____________________________
(Work): __________________
      Email:
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