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PLEASE PRINT OUT & FILL IN YOUR DETAILS IN BLOCK CAPITALS AND RETURN THIS ENTIRE CERTIFICATE TO:

Breaking Your Mould, Codestorm House, Walton Road, Farlington, Hampshire PO6 1TR

Name ..……………………………………………….....……………...      (Mr/Mrs/Miss/Ms)

Address .................................................................................................

..................................................................................................... Post Code ...................................

Email..........................................................................................Tel ...........................................…..

(Your telephone number is optional but is important if we need to contact you about delivery of your package.)

I wish to receive the course monthly and pay by Standing Order, (please complete the form below):

Note:- The form below is a delayed action STANDING ORDER mandate, NOT a DIRECT DEBIT. You can cancel a standing order at any time, by notifying your bank. We DO NOT have the right to debit varying amounts. A standing order mandate is completely under YOUR control. Please note that Building Societies do not always offer standing order facilities. Please check with them first.

IF PAYING BY STANDING ORDER, PLEASE INSERT YOUR BANK DETAILS BELOW

Materials are sent monthly for every month for which you have paid. Note, it can take up to 10 working days for the bank to pay the first standing order payment, so please be patient. You may withdraw from the course at any time without penalty , simply by notifying your bank that you wish to terminate your standing order.

To: (Your Bank, e.g. Lloyds).................................Bank PLC. Sort Code........................

Full Branch Address ............................................................................…………........………..

........................................................................... Post Code ..................….........…………………

Account Number .................................................................................

Name of Account (E.g. “J Smith”).................................................

Please pay to the order of Breaking Your Mould, A/C No 10689556, at Barclays Bank PLC, 52 Abbeygate Street, Bury St. Edmunds (20-16-12) the sum of £23.97 (twenty three pounds and ninety seven pence) immediately upon receipt of this mandate and the same sum at monthly intervals until cancelled by me in writing.

Signed ............................................................................. Date ........................................

Guarantee   Examine Lesson One of the Inner Circle in your home for 30 days. If you are not 100% satisfied that this can make you wealthy, then simply cancel your subscription. You may keep Lesson One and your copy of ‘The Midas Method’ with our compliments as a 'thank you' for taking a look at the course. If ordering the full course, please return within 30 days of receipt for a full, no quibble refund of your money.

Breaking Your Mould, Codestorm House, Walton Road, Farlington, Hampshire, PO6 1TR