IRELAND ONLY

Sign up form for Direct Debit to Greenpeace from your bank account

Please print this form off and return by regular mail to:

Do not return it directly to your bank. Do not send this document by fax, it must be sent by mail, as the bank requires an original signature.

I/We would like to join Greenpeace by giving a gift of:
monthly	€6 €12 €18   My choice €____
annually	€32 €64 €128   My choice €____
Name:	___________________________
Address:	___________________________ ___________________________
Telephone number (including area code):	___________________________
Email address:	___________________________
Instructions to your Bank or Building Society to pay Direct Debits:
Originator's identification number:	3 0 2 1 8 5
Name and full postal address of your Bank or Building Society branch:
Bank Name:	___________________________
Bank address:	___________________________ ___________________________
Name(s) of account holder(s):	___________________________ ___________________________
Account number:	___________________________
Branch sort code:	___________________________
Greenpeace reference number (for bank use only):	___________________________
Instructions to your Bank or Building Society:
This is a guarantee provided by your own Bank as a member of the Direct Debit Scheme, in which Banks and Originators of Direct Debits participate. If you authorise payment by Direct Debit, then Your Direct Debit Originator will notify you in advance of the amounts to be debited to you account Your Bank will accept and pay such debits, provided that your account has sufficient available funds If it is established that an unauthorised Direct Debit was charged to your account, you are guaranteed a prompt refund by your Bank of the amount so charged. You can cancel the Direct Debit Instruction by writing in good time to your Bank.
Signature:	_________________
Date:	_________________
Banks may not accept Direct Debit instructions for some types of account