DATE ;

To; The Manager :________________________

I/We hereby authorise and request you to debit my/our

Account Number :

With the sum of €

And to credit

Lions Club of Ennis - friends of the Lions Account

Account Number Payee Reference

42606185

Bank NSC

AIB Bank Ennis, 93 53 87

Start Date :

Until Further Notice in writing.

It shall be understood that the Bank shall not be under any liability for damage
or loss caused by any omission to make these payments.

Please allow 5 working days notice prior to first payment.

Name/Account Title ( Block Capitals) _________________________________-

Signature _______________________________