Please print this form, complete it by hand and send/give it to your bank.

To: (your bank) …………………………………………………………….

Address of bank: …………………………………………………………….

…………………………………………………………….

Please pay to: Triodos Bank

Brunel House

11 The Promenade

Bristol BS8 3NN

Account name: Media Lens
Sort code: 16-58-10
Account number: 20021933

The sum of £………..

Amount in words: ………………………………………………………………

Date of first payment: ……………………

and thereafter every ………………….. week(s) / months

Until: ………………….. (date) or until cancelled by me in writing.

Account to be debited: ……………………………………………………….

Account number: ……………………………………………………….

Sort Code: …… - …… - ……

Reference: www.medialens.org

Signature(s): ………………………………………… Date: ……

………………………………………… Date: ……