Direct Debit - Great North Air Ambulance Service

Direct Debit

Fill in the form below to submit a direct debit authorisation.

Please select your preferred payment date and enter your personal details below and click Submit to complete.
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Name*
Title First Last
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Contact number*
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This is my
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Email address*
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Address*
ZIP / Postal Code
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Address*
Street Address Address Line 2 City Country
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Please tick the box if you would like to hear about the following (tick all that apply):
- Our newsletter
- Our upcoming events and campaigns
- Our annual raffle
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How would you like to receive this information? (tick all that apply)
- Email
- Post
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- You've indicated that you don't want to be contacted about our missions, events and campaigns. But it doesn't have to be goodbye for good. We may still contact you from time-to-time about things we think are relevant to you. If you really don't want to hear from us again, please tick this box. If you are happy for us to contact you occasionally, please continue to the next step.
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Referrer URL
Select preferred payment date*
- 1st of month
- 15th of month
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First payment date*
First payment date must be on either the 1st or the 15th of the month.

Day
Month
Year
Please enter your account details below - these will be automatically checked.
If you are not the authorised signatory for this account, please download and complete a paper mandate below
Please enter your account details below - these will be automatically checked.
If you are not the authorised signatory for this account, please download and complete a paper mandate below
Paper Mandate
Please confirm that the account is in your name and you are the only signatory required to authorise this direct debit.*
- I confirm
Account name*
Sort code*
Account number*
Bank*
Branch
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Agreement reference number
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Cost per year

Direct Debit Fill in the form below to submit a direct debit authorisation.

Direct Debit

Fill in the form below to submit a direct debit authorisation.