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GONDAR (ETHIOPIA) EYE SURGERY BANK STANDING ORDER MANDATE To: Bank ……………………………………… Sort Code ............................................. Branch ................................................................................................................................ Address .............................................................................................................................. ............................................................................................................................................. Please make the payments detailed below debiting my/our* Account number ………………………………. Please pay to: HSBC, Abergavenny, sort code 40-08-04, Gondar (Ethiopia) Eye Surgery, Account no 71423800. starting on the …….……….… day of …….………………….……………. 200……… the sum of ........................................................................................................................... and the same sum on the same day Monthly* Quarterly* Annually* until further notice Donor’s name and initials in capitals: (Mr/Mrs/Miss/Ms/Title) ..................................................................................................... Address .............................................................................................................................. ............................................................................................................................................. Signature ............................................................................................................................ * delete as appropriate Please do not send this form directly to your bank, Send it to: Gondar (Ethiopia) Eye Surgery Cefn Maen, Usk Road, Raglan, Mon NP15 2HR Charity Number 1101246