Adkins Payments Form V2.4

Adkins Research Group - Incentive Payments

Please complete the following form to securely submit your payment information

This is Fully GDPR compliant, items with a * are required.

Name

Enter Your First Name & Surname.

Specialty

Enter your specialty

Contact Number

Enter your preferred contact telephone number

Enter your email address

Preferred Payment Method

Select payment method and remember to complete all the relevant parts of the form

Which Vouchers You would like to receive.

Select Vouchers You would like to receive. These will be emailed to you using the email that you have entered

Name as it appears with your Bank

Bank Name

Enter the Name of Your Bank that we are making payment to.

Bank Sort Code

Enter your Bank's Sort Code in the format XX-XX-XX eg 12-34-56

Account Number

Ensure that the account number is is entered in the following format NNNNNNNN. eg. 12345678

Postal Address

Complete postal address including post code

We are committed to securing all information provided by you. By submitting this form, you are agreeing to allow the Adkins Research Group to save your preferred payment details. These will be stored securely and only accessible by the Adkins Research Group for the purposes of payment. for more information on our Privacy Policy, please click the link below.