Name a Seat Brochure A5 4pp l.let:Layout 1 21/02/2014 12:17 Page 1
Instruction to your Bank or Building Society to pay by Direct Debit
Name A Seat Birmingham Hippodrome Hurst Street Birmingham B5 4TB
ORIGINATOR’S IDENTIFICATION NUMBER:
8 | 3 | 0 | 9 | 0 | 8 REFERENCE (to be completed by Birmingham Hippodrome):
NAME(S) OF ACCOUNT HOLDER(S):
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BANK/BUILDING SOCIETY ACCOUNT NUMBER:
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Instruction to your Bank or Building Society Please pay Birmingham Hippodrome Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct debit Guarantee. I understand that this Instruction may remain with Birmingham Hippodrome and, if so, details will be passed electronically to my Bank/Building Society.
BRANCH SORT CODE:
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N E IO AR SS SH PA UR YO
Please fill in the whole form using a ball point pen and send it to:
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Name and full postal address of your Bank or Building Society TO: THE MANAGER BANK/BUILDING SOCIETY: ADDRESS:
SIGNATURE(S):
POSTCODE:
DATE:
(To be completed by Birmingham Hippodrome)
BOOKING REF:
EXPIRY DATE:
PROCESSED BY:
DATE PROCESSED:
Please read this guarantee information before signing. A copy of this will be sent to you for your records.
The Direct Debit Guarantee • This guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme. The efficiency and security of the Scheme is monitored and protected by your own Bank or Building Society. • If the amounts to be paid or the payment dates change, Birmingham Hippodrome Theatre will notify you ten working days in advance of your account being debited or as otherwise agreed. • If an error is made by Birmingham Hippodrome Theatre or your Bank or Building Society, you are guaranteed a full and immediate refund from your branch of the amount paid. • You can cancel a Direct Debit at any time by writing to your Bank or Building Society. Please also send a copy of your letter to us.
Supporting the UK’s most successful theatre
Name a Seat Brochure A5 4pp l.let:Layout 1 21/02/2014 12:17 Page 3
NAME A SEAT
PLEASE COMPLETE THIS FORM AND RETURN IT TO THE ADDRESS OVERLEAF OR SCAN AND EMAIL TO DEVELOPMENT@BIRMINGHAMHIPPODROME.COM
YOUR DETAILS TITLE:
FORENAME:
SURNAME:
ADDRESS:
POSTCODE:
TELEPHONE (DAY/EVE):
EMAIL:
NAME A SEAT DETAILS
Naming a Seat at Birmingham Hippodrome is a wonderful way to share your passion for the theatre, remember a loved one, or commemorate a special occasion - and it makes a great gift! What’s more you will be playing a part in ensuring the theatre’s exciting future as a centre of excellence for generations to come. From as little as £250 you can dedicate a seat of your choice* in the main auditorium with your personalised inscription for a period of 10 years.
I wish to name
seat(s) in the Circle/Stalls (PLEASE DELETE AS APPROPRIATE)
PLEASE CAREFULLY WRITE IN CAPITALS THE TEXT YOU WISH TO BE DISPLAYED. YOUR CHOSEN INSCRIPTION CAN BE UP TO 10 WORDS IN LENGTH.
Tick this box if this is a gift
PAYMENT DETAILS The cost to name a seat in our auditorium is £250 and your plaque will be displayed for 10 years. I enclose a CHEQUE made payable to Birmingham Hippodrome I wish to pay by CREDIT/DEBIT CARD (PLEASE COMPLETE THE SECTION BELOW)
To Name your Seat, simply complete and return the form opposite or contact 0844 338 5040 / development@birminghamhippodrome.com for more information. Your donation for this dedication will directly support Hippodrome Plus our programme of education, access and community work. *Subject to availability.
I wish to pay in TEN INSTALMENTS by Direct Debit (PLEASE COMPLETE FORM OVERLEAF) Please include an additional donation of £
. My total payment is £
.
NAME ON CARD:
CARD NUMBER:
.... .... .... .... / .... .... .... .... / .... .... .... .... / .... .... .... .... TYPE OF CARD:
START DATE:
EXPIRY DATE:
MAESTRO / MASTERCARD / VISA / AMERICAN EXPRESS CVV CODE:
SIGNATURE:
GIFT AID DECLARATION If you are eligible for Gift Aid, please sign the declaration below to increase your support at no extra cost to you.
Birmingham Hippodrome Theatre Development Trust
I would like Birmingham Hippodrome (Registered Charity number 511567) to treat all donations I have made since 6 April 2008 and all donations I make hereafter as Gift Aid donations, unless I notify you otherwise. I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year that is at least equal to the amount of tax that all charities I donate to will reclaim. I understand that other taxes such as VAT and Council Tax do not qualify. I confirm I will notify Birmingham Hippodrome if I wish to cancel this declaration, if my name or address changes or if I no longer pay sufficient tax as described above.
SIGNATURE:
Registered Charity No. 511567