Charity or group name: Name: Email address: Address:     Postcode: Telephone number: Fax number:     Does your organisation have a bank account with two signatories? Yes No Registered charity number: Are you collecting mobile phones for - Cash Dixons Group vouchers If cash, who would you like cheques made payable to? Annual income of organisation £1 - £10,000  £1,000,000 - £5,000,000 £10,000 - £100,000  £5,000,000 plus £100,000 - £1,000,000             Is there anything in particular you are collecting funds for/would like offers sent to you on? Please tell us where you heard about the scheme Your details may be passed onto Dixons Group Business Services who may approach you about products and services that may be of interest to you. If you do not wish to be contacted please tick this box. Community Fonebak, The Link and Fonebak have the right to refuse participation in the scheme to any organisation which does not appear to benefit the community.