Donation Form

Please complete your details.  Please tick if you do not want your donation acknowledged

Title: (Mr/Mrs/Miss/Ms/Dr/Other)
Full Name:
Address:
Postcode:                            Tel:
Email:

Payment: Please tick :

I enclose a cheque/postal order payable to Epilepsy Wales for £ *****
(For security reasons do not send cash)
I wish to donate each month by standing order
Please forward a standing order form
Please charge my Credit Card

My card number is:

Valid from:      DD/MM/YYYY            Expiry date: DD/MM/YYYY   Issue No: (If applicable)

Your support gives us a powerful voice.  We are grateful for any amount that you can afford to give.
Thank you.

GIFT AID DECLARATION

I am a UK taxpayer and I authorise Epilepsy Wales to receive the tax on my donations
(unless I notify you otherwise).

Signature:
Print your name:
Date:

Please return this form to –

Epilepsy Wales
Bradbury House
23 Salisbury Road
Wrexham LL13 7AS

Protecting your data: Epilepsy Wales is registered under the Data Protection Act 1998.
Your name and personal details will be stored on our database and will NOT be passed to any
other organisation.

Epilepsy Wales Charity No 1059067

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