Monthly Donations – Radiothon

Your Details

Title *

First Name *

Surname *

Company / School / Club Name

E-Mail *

E-Mail Again *

Address Line 1 *

Address Line 2 *

Address Line 3

Address Line 4

Town/City *

County *

Eircode

Eircode (your Eircode has 7 characters)

Country *

Phone number

Eg. +353 87 1234567 or +353 21 7654321

If you have any stories or any additional information to add please type it here.

Bank Details

Before we can take your bank account details and sign you up to a direct debit online, please confirm the following by ticking the boxes below:

Is Bank account a ROI bank account?

Yes

Can bank account accept Direct Debit?

Yes

Is more than one signatory required to sign on your account?

Yes

We will send you a direct debit mandate form

How much do you want to donate per month? (EUR) *

Name of Account Holder *

IBAN

IBAN stands for International Bank Account Number. It contains your Bank Account Number and a new code so that your bank account can be used throughout the EU. An example of an IBAN: IE99AIBK90000012345678 - NO SPACES, DASHES ETC.

Your IBAN can be found on your bank account statement.

BIC

BIC stands for Bank Identifier Code. BIC codes are specific to each bank within the EU (replacing sort codes). They can be found on your Bank statement or can be requested from your bank. Your BIC can be found on your bank account statement.

Please note this is a recurring donation.

Your direct debit will be taken out of your account on the 4th Friday of every month.

Would you like to receive updates regarding the Giving for Living Radiothon? Tick or untick the boxes as you wish.

I'd like to be updated by post *

Yes

I'd like to be updated by phone *

Yes

I'd like to be updated by e-mail *

Yes

I'd like to be updated by text message *

Yes

I'd like to be updated about this event only *

Yes I am happy to receive emails about this particular event

No, I do not want to receive any emails at all from The Mercy Hospital Foundation

If you would like to receive emails about this event only from The Mercy Foundation please tick your choice below