BANKER'S ORDER FORM

To: The Manager of

.................................................

Bank / Building Society

Address

..............................................................................................................

Post Code ...........................

SORT CODE

Please pay CO-OPERATIVE BANK PLC, 151/155 Hoe Street, Walthamstow, London, E17 3AN

SORT CODE 08-90-30 to the credit of WALTHAM FOREST THUSO IN SOUTH AFRICA

ACCOUNT No. 50061730 the sum of (amount in figures) £ / amount in words

........................................................ each month/quarter/year* until further notice starting

on / / 200 and debit my account

NUMBER

Signed

..............................................................................................................

Name (please print)

..............................................................................................................

Address (please print)

..............................................................................................................

Post Code ...........................

*delete as applicable

Please return completed form to:

Treasurer, 7, Rectory Road, Walthamstow, London, E17 3BG