To the Manager (please print the name of your bank below)

Bank: __________________________________________

Address: __________________________________

__________________________________

Post Code: __________________

Please pay
Royal Bank of Scotland
Lockerbie Branch
47 High Street
Lockerbie
DG11 2JH

Sort Code 83-25-03
Acc no 00183202

£: _________ monthly: ____ quarterly: ____ annually: ____

Starting on: __________________ 200___

And debit my account number: __________________________

My reference: ___________________________

Name: __________________________________________

Address: __________________________________

__________________________________

Post Code: __________________

Signature: __________________________________

Date: __________________

Please return this form to:

Kagyu Samye Dzong Edinburgh
c/o Kagyu Samye Ling Monastery and Tibetan Centre
Eskdalemuir
Langholm
Dumfriesshire
DG13 0QL
Scotland, U K.X

Kagyu Samye Dzong Edinburgh is part of ROKPA Trust
registered charity number 1059293.