Forget Me NotNow I am gone, let my memory live on.

Create a lasting tribute by gifting a donation in memory of a loved one.

Because you care, we can care.

The Forget Me Not donation is a unique and lasting way to remember someone dear to your heart. There are a number of ways you can donate:

• Complete the form below and return to St Andrew’s Hospice

• Call the Fundraising Department on 01236 766951

• E-mail: lorna.mccafferty@standrews.scot.nhs.uk

Donation Form

Name ...........................................................................................................................................

Address (inc. postcode) ................................................................................................................................................................................................................................................................

If your donation is in memory of someone and you would like to tell us, please provide their name: ..................................................................................................

Amount of donation £ ...................... Cheque Cash Standing Order

If you wish to set up a standing order, we will send a standing order form to you.

Please tick here if no acknowledgement is required

Gift Aid Declaration: Are you a tax payer? Yes No

Surname ....................................... (Mr/Mrs/Miss/Ms)

First Name(s) ..............................................

Address (inc. postcode) ................................................................................................................................................................................................................................................................I confirm that the personal details (name, address etc) on this form relate to me. I will notify any change to my name or address to St Andrew’s Hospice. I want all donations I have made to St Andrew’s Hospice during the last 4 years, and all donations I make thereafter, to be treated as Gift Aid donations and I want the Hospice to reclaim tax on my donations under the Gift Aid scheme. I understand I can cancel this declaration at any time.

Signed .........................................................................................................................................

Gift Aid allows us to claim back 25p for every £1 you give us, boosting the value

of your donation by a quarter. All you have to do is sign the declaration.

Date ...............................

Please send your completed form to: St Andrew’s Hospice, Henderson Street, Airdrie ML6 6DJ

Please select the ways we can keep in touch with you:

Post E-mail Text Message Telephone No Contact

St Andrew’s Hospice (Lanarkshire) is a charity registered in Scotland, No SC010159