Gilwiskaw Aqueduct ‘Buy a Brick’ Appeal Application Form

Brick type? *

Choose your inscription

Personalised bricks can be inscribed with a maximum of 2 lines per brick with a character limit of 17 per line (including any spaces).

Inscriptions will be EXACTLY as you enter them into this form so please make sure you use upper case letters where desired and double check your entries.

Please enter the 1st line of your inscription *Maximum of 17 characters (including spaces)0 / 17

Please enter the 2nd line of your inscription *Maximum of 17 characters (including spaces)0 / 17

Please enter any specific requests below**We will do our very best to honour reasonable requests where this is possible.

Would you like to include an additional donation? (optional) *

Donation amount *

GBP

Please enter an amount in whole £'s

Name

Prefix

First Name *

Last Name *

Address

1st Line of Address *

Town *

County *

Post Code *

Country

Contacts

Phone NumberIn case of any queries

Email Address *

Donating through Gift Aid means our charity can claim an extra 25p for every £1 you give.

It will not cost you any extra

Gift Aid Declaration *

Yes, I am eligible for Gift Aid

By selecting “Yes” I confirm that I want to Gift Aid my donation on this form and any donations I make in the future or have made in the past 4 years to the Ashby Canal Association. I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference. I will notify the Association if I want to cancel this declaration, or I change my name or home address or I no longer pay sufficient tax on my income and/or capital gains. For more details please visit the HMRC website.

No, I am not eligible for Gift Aid

I am not a UK taxpayer or I will not pay sufficient Income Tax and/or Capital Gains Tax in the current tax year to allow the Association to reclaim Gift Aid. For more details please visit the HMRC website.

To complete your 'buy-a-brick' application and make your payment please enter you credit/debit card information below and click 'Submit'.

To complete your donation please enter you credit/debit card information below and click 'Submit'.

Total

Credit / Debit Card *