Please print out this form, fill it in and return to:

The Administrator, Winchester Youth Counselling, Jubilee House, 1-3 Swan Lane, Winchester, SO23 7AA.

I apply to become a Friend of WYC

Surname:

Other Names:

Title:

Address:

Postcode:

Telephone:

Email:

I enclose a cheque / banker's draft, made payable to Winchester Youth Counselling, in the sum of: (Please tick / select as appropriate)

I would like to donate £50 ____ £25 ____ Other £ ___________

PLEASE GIFT AID YOUR DONATION

I confirm that I am a taxpayer and authorise Winchester Youth Counselling to recover Income Tax and the Standard Rate on all my recorded gifts to its funds from 6th April 2003 until this authority is cancelled in writing.

Surname:

Other Names:

Title:

Address:

Post Code:

Telephone No.:

Signature ________________________________________________________

Date ___/___/_____

This declaration should only be completed if you are a tawpayer. Note you are able to cancel this authority if your circumstances change. Any cancellation should be done in writing.