Collection tin pay in form

Name

Address (including postcode)

Phone number

At Parkinson’s UK we want to be very clear about how we use, store and protect your personal data, which you can read about at parkinsons.org.uk/privacy. We will not sell your details to third parties.

Date the collection was counted

Date the collection was banked

Site of collection tin

Collection tin number

You'll find the collection tin number on the right hand side of the collection tin label.

Name of collection counter 1

Please note that we may need to request contact details for the collection counters.

Name of collection counter 2

Total amount collected, counted and banked

Please choose one of the following:

I have sent a cheque

I have paid by phone

I have paid online

Payer name

Payer reference number (if known)

I confirm the above information is correct.

Notes