Instruction to your bank or building society

to pay by Direct Debit

Please fill in this form and send to: Research Autism, 25 Nutford Place, London W1H 5YQ

Name and full postal address of your bank and building society

To the Manager of
Bank/building society:
Address:
Postcode:

Name(s) of account holders:

Branch sort code:

Bank/building society account number:

Service user number:

4 / 4 / 1 / 6 / 0 / 1

Reference:

Friends of Research Autism

Instruction to your bank or building society

Please pay Research Autism 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 Research Autism and, if so, details will be pass electronically to my bank/building society.

Signature(s)
Date


Banks and building societies may not accept Direct Debit instructions for some types of account.

This Guarantee should be detached and retained by the payer.

The Direct Debit Guarantee

  • This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
  • If there are any changes to the amount, date or frequency of your Direct Debit Research Autism will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Research Autism to collect a payment, confirmation of the amount and date will be given to you at the time of the request
  • If an error is made in the payment of your Direct Debit, by Research Autism or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society.
  • If you receive a refund you are not entitled to, you must pay it back when Research Autism asks you to
  • You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

Become a friend of Research Autism

Research Autism is the only UK charity exclusively dedicated to

research into interventions in autism.

About our Friends scheme

By becoming a Friend, your organisation can help us to transform the lives of people with autism now and in the future by making a regular financial contribution towards our work. As a Friend, a nominated member of your staff will have access to:

• Regular weekly and monthly bulletins on the latest news and research from around the world,

delivered straight to your inbox

• Discounts on delegate rates for Research Autism conferences, which address the latest thinking

in autism

• Free online access to presentations from our conferences from renowned speakers. Previous

conference speakers have included Professor Simon Baron-Cohen, Professor Christopher

Gilberg, Dr Lorna Wing and others.

Sign up now and join our exclusive scheme.

Friends’ minimum annual contribution rates:
UK based individuals: £24

UK concessionary rates (students, on benefits): £12

Overseas based individuals: £36

Organisations: please contact us for details

Sign up online at or complete the friendship form overleaf

Research Autism, 25 Nutford Place, London W1H 5YQ

Tel: 020 3490 3091; Email: ; Registered Charity No: 1096508

Research Autism Friendship Form
Please complete and return this form to Research Autism with a cheque, postal order or your debit/credit card details.
1. Tell us about yourself
Title / Forename/s
Surname
Address
Postcode / Country
Email address
Preferred email Format / HTML (with graphics) / Plain text
2. If you are happy to, please tell us about your connection(s) to autism:
Autistic person / Education Provider / Other (please specify below):
Parent or carer
Researcher / Health/Social Care Provider
Policy Making/Campaigner
3. Tell us what you would like your nominated staff member to receive:
Weekly email news bulletin on autism from around the world
Monthly email news bulletin on autism research from around the world
Regular email updates on the work of Research Autism inc. our newsletter
Presentations from Research Autism conferences and other events
Discount on delegate rates at Research Autism conferences and events
4. Privacy statement:
Please tick this box to indicate that you understand thatResearch Autism will store the information you have provided securely for the purposes of administrating your membership of this Friendship scheme.
5. Tell us how much you wish to pay(please see page one for annual contribution rates)
I wish to make a one-off payment for one year: / £
Iwish to set up a direct debit to make an annual contribution of: / £
Iwish to set up a direct debit to make a monthly contribution of: / £
I wish to add a one-off contribution of: / £

6. Choose your payment method

Direct DebitPlease complete the Direct Debit form on page one of this leaflet. If you pay by Direct Debit payments will be taken at the interval and amount that you have indicated you wish to pay in the table above.
Cheque/Postal order – payment for one year
Please make your cheque or postal order payable to Research Autism and send it with this form to Research Autism, 25 Nutford Place, London W1H 5YQ.
Credit/Debit card (payment for one year). Please complete the details below:

I wish to pay using my Mastercard/Visa/Maestro card/Solo/American Express card

Card holder’s name:

Card Number:

Security No / Issue No / Start date / Expiry date

7. Please return this form to: Research Autism, 25 Nutford Place, London W1H 5YQ.

For Research Autism office use only: Membership Type: ______Membership No: ______Renewal Date: ______