TO MAKE A CONTRIBUTION TO THE

GLOUCESTERSHIRE PROSTATE CANCER (BRACHYHERAPY UNIT)TRUST

PRINT THIS FORM

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I, (Name)......................................................................................of (Company or Organisation)

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Address: ………………………………………………………………………………... …………………………………………………………………………………. ………………Telephone:…………………………..… Fax: ………………………………………....
E-mail ………………………………………………………………………………..….

Declare that I give the sum of ………………………………..pounds (£…………) to the Gloucestershire Prostate Cancer (Brachytherapy Unit) Trust and I wish the gift to be within the Gift Aid scheme. (Subject to Inland Revenue approval)

(Cheques made payable to 'GPCT')

Signed……………………………….

Payments to be addressed to Walker Gibb Chartered Accountants Regal House 61 Rodney Road Cheltenham GL50 1HX

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