To: The Chief Executive, St. Luke's Hospital for the Clergy, 14 Fitzroy Square, London W1T 6AH
I am a tax payer and I want it to be treated as a Gift Aid Donation.
Date:...................................... I enclose a cheque for the sum of £.............................
Signed........................................................................
Rev/Mr/Mrs/Miss/Ms...................................................................................................
Address:......................................................................................................................
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To: St. Luke's Hospital for the Clergy.
I promise to pay you for ........................... years or until I die, if earlier, the amount of ...................................... each month/ quarter/ year.
I am a tax payer and wish these donations to be treated as Gift Aid Donations.
Signed........................................................................
Date............................. Full name............................................................................
Address.....................................................................................................................
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To:............................................................Bank 
Sort Code............................. Account Number........................................
Address of Bank...............................................................................................................

Please pay on the ............. day of ................................. 20......... to:
Yorkshire Bank, 46-48 Oxford Street, High Wycombe, HP11 2XQ 
Sort Code 05-04-70  Account No. 61416938
the sum of £.................... and continue to pay the same amount monthly / quarterly / annually on the ........................ in each future year.
Signed............................................. Full Name................................................................
Address ..........................................................................................................................

Send this page (or a photocopy) with both parts completed to: St. Luke's Hospital for the Clergy, 14 Fitzroy Square, London W1T 6AH
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Send this form with this part completed to:
St. Luke's Hospital for the Clergy, 14 Fitzroy Square, London W1T 6AH
Cardholder Name....................................................................................... (as on your card)
Cardholder's Address  .........................................................................................................
Credit Card/ Charity Card No. ..................................................... Exp. Date.........................
Amount of Donation £...................... ........Amount in words ................................................
Cardholder's signature ......................................................................
Card ID No (the last three digits of the number on the signature strip) .................................
I am a tax payer and want this to be treated as a Gift Aid Donation

By Telephone

Ring . Ask for the Charity Administration Office and give details as above
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