Good Hope Hospital
NHS Trust

Donation Form
Please print out and fill in. Once complete send return this form to

Finance Director
Good Hope Hospital NHS Trust
Rectory Road
Sutton Coldfield
B75 7RR

Telephone: 0121 378 6027

(Please Print in capitals)

I/We wish to name a bed in Good Hope Hospital.

Name for "Honoured Supporters" Board __________________________________

Donor's name ______________________________________________________

Address __________________________________________________________

__________________________________________________________________

Postcode _____________________ Telephone Number ____________________

Signature ____________________________________Date _________________

Please treat as a Gift Aid donation Tick Here

Signature ____________________________________Date _________________

Cheque payable to:
Good Hope Hospital CharitableFunds A/C

Please tick appropriate box

Personal Donors

Cheque for £1000 enclosed. Gift Aid will boost my gift to £1282.

Cheque for £780 enclosed. Gift Aid will boost my gift to £1000.

Cheque or Charity Voucher for £1000 enclosed. I / We do not qualify for tax relief.

£1000 donation through bank standing order. Gift Aid will boost my gift to £1282.

Company Donors

Cheque for £1000 enclosed. Please send receipted invoice

Bank Standing Order

To ________________________________________________________ Bank plc

Address __________________________________________________________

_________________________________________________________________

_____________________________________ Postcode ____________________

Debit my/our Account No:______________________________________________

In the name of: ______________________________________________________

_________________________________________________________________

The sum of £250 (TWO HUNDRED & FIFTY POUNDS) on the 1st day of
__________________________and a further £250 on the 1st day of the
next three following quarters (i.e. at 3 monthly intervals)

or

The Sum of £84 (EIGHTY FOUR POUNDS) on the 1st day of
__________________________ and a further £84 on the 1st day of the
following eleven months. This makes a total of £1008

CREDIT GOOD HOPE HOSPITAL CHARITABLE FUNDS A/C

BANK: Nat West Bank plc., 6 The Parade, Sutton Coldfield B72 1 QT

ACCOUNT NAME: Good Hope Hospital Charitable Funds Account

SORT CODE: 60-21 -07

ACCOUNT No: 22820124

Signature ____________________________________Date _________________

Registered Charity 1058533