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Direct Debit Mandate Please read the notes below, complete this application form in BLOCK CAPITALS, and post to CII, Customer Service 42–48 High Road, South Woodford, London E18 2JP or fax (+3052).
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Document Date: 2014-05-07 14:38:25

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City

Sao Tome / York / Canterbury / Coventry / Burnley / Leicester / Bradford / Bristol / Gloucester / Plymouth / Manchester / Exeter / Chester / Stoke-on-Trent / Rep. / Reading / Nottingham / Lincoln / Newcastle / Aberdeen / Timor Leste / Principe / Preston / Southampton / Leeds / Perth / Sheffield / Birmingham / Halifax / Liverpool / Belfast / Cambridge / Cardiff / Norwich / Gaza / Samoa / Glasgow / London / Edinburgh / /

Company

UK Bank / CII Group / The World Bank Country / /

Country

Comoros / Maldives / Rwanda / Senegal / Nepal / Yemen / Nicaragua / Tonga / Turkmenistan / Ecuador / Niger / Marshall Islands / Myanmar / Mongolia / Burundi / Guatemala / Tajikistan / Cambodia / Honduras / Lesotho / Egypt / Thailand / Kenya / Mauritania / Pakistan / Uganda / Afghanistan / Malawi / Guyana / Vanuatu / Guinea-Bissau / Burkina Faso / Moldova / Tuvalu / Tanzania / Korea / Liberia / United Kingdom / Cape Verde / Philippines / China / Ethiopia / Iraq / India / Somalia / Eritrea / Cameroon / Wales / Isle of Man / Zambia / Micronesia / Central African Republic / Kiribati / Haiti / Benin / Solomon Islands / Tunisia / Bangladesh / Kyrgyzstan / Mozambique / Armenia / Swaziland / Sudan / Zimbabwe / Congo / Guinea / Sri Lanka / Mali / Gambia / Indonesia / Sao Tome and Principe / Uzbekistan / Azerbaijan / Jordan / El Salvador / Syria / Angola / Vietnam / Togo / Paraguay / Chad / Nigeria / Djibouti / Georgia / Morocco / Madagascar / Belize / Ghana / Papua New Guinea / Bolivia / Ukraine / Bhutan / Sierra Leone / /

Currency

GBP / /

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Facility

Signature Date The Chartered Insurance Institute / Chartered Insurance Institute / Insurance Institute of London / Building Societies / Building Society / Insurance Institute / /

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IndustryTerm

company underwriters / insurance / insurance broker / knowledge services / /

Organization

Life & Pensions Faculty / Insurance Institute of London / Practitioner and Insurer SMP / Chartered Insurance Institute / All / Insurance Broking Faculty / Building Society / Bank/Building Society / World Bank / Underwriting Faculty / Claims Faculty / London Market Faculty / /

Person

Milton Keynes / /

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Position

Chartered Insurance Broker / Manager / MP / insurance broker / /

Product

Essex / /

ProvinceOrState

Kosovo / Swansea / West Bank / Peterborough / Northampton / St Albans / /

Region

West Wales / North Wales / /

URL

www.cpd.cii.co.uk / www.cii.co.uk/code / www.cii.co.uk/directdebit / www.cii.co.uk / /

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