Please print out and complete this form and send it with your donation to Cancer Research Wales, Velindre Hospital, Whitchurch, Cardiff CF4 7XL. A copy of the form will be returned to you. Please make cheques payable to Cancer Research Wales.
I __________________________________________________________________
of _________________________________________________________________
____________________________________________________________________
herby covenant to pay Cancer Research Wales for a period of four years (or during my lifetime if shorter), such a sum which after the deduction of income tax at the basic rate, amounts to:
� ________________ each week / month / year (Delete as appropriate)
from (date) ___________________________________________________________
Sign & Delivered _______________________________________________________
Date ________________________________________________________________
WITNESSED BY:
Signed _______________________________________________________________
Full name _____________________________________________________________
Address _____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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