Payroll pledge form

Amount: Please select £5 £10 £15 £20 £25 other

If you have selected other, please specify amount you would like to donate:

Title: Mr Mrs Miss Ms Prof Dr Lord Lady Sir

First name:

Surname:

Email:

I would like to be kept up to date with RNIB news and activities.

Daytime telephone number:

Employee number:

Employer/Pension provider:

Payroll department address line 1:

Payroll department address line 2:

Payroll department address line 3:

Payroll department town/city:

Payroll department county:

Payroll department postcode:

Home address line 1:

Address line 2:

Address line 3:

Town/City:

County:

Postcode:

Format required: Standard print Large print Braille Tape

Any questions or comments

Declaration

Please deduct the total amount above from my gross pay every month as a gift to Royal National Institute of Blind People. I confirm that my understanding is that no further tax is recoverable on this gift. I understand that no gift can be made as a membership subscription or to pay for goods or services supplied.

I agree to the above declaration