Form TH10: Boat registration – Direct Debit application form – Thames
TH10 Version 6, October 2017 page 1 of 2
Boat registration – Direct Debit
application form – Thames
Please complete the whole form in capital letters
and post it to the address below – emailed forms
can not be accepted:
Environment Agency, Boat Registration, PO Box 544,
Rotherham, S60 1BY
For advice on completing this form please contact
03708 506 506 or email boatreg@environment‐agency.gov.uk
You only need to send us the first page.
Please read the Direct Debit Guarantee and explanatory notes
on page two. This should be kept for information.
1 Boat registration number and name
Boat registration number, if available Office use only
Boat name
2 Boat owner details
Boat owner name
Title (Mr, Mrs, Miss and so on)
First name Last name
Address
Postcode
Contact numbers, including the area code
Phone Fax Mobile
Email
3 Payment plan
Please indicate your preferred payment plan, by ticking the relevant box below. If you do not make a selection, or your selection is
unclear, we will take one payment from your bank account. Please be aware that it can take time to process your application. If this
happens, or you send your application in late, we may not have time to set up 10 payments. In this situation we will split the full cost
over the remaining months to the end of October. For example, if we receive your request at the end of April it is likely your payment will
be split over six months (May–October).
One payment
Six payments (January–June)
10 payments (January–October)
Calls to 03 numbers cost no more than a national rate call to an 01 or 02 number
and must count towards any inclusive minutes in the same way as 01 and 02 calls.
These rules apply to calls from any type of line including mobile, BT, other fixed
line or payphone.
Instruction to your bank or building society to pay by Direct Debit
Please fill in the whole form using a ball point pen and send to:
Environment Agency – Boat Registration, PO Box 544, Rotherham, S60 1BY
Name and full postal address of your bank or building society
To The Manager: Bank or building society
Address
Postcode
Name of account holder
Bank sort code
Bank or building society account number
Service user number
4
1
1
0
0
2
Reference
Instruction to your bank or building society.
Please pay Environment Agency Direct Debits from the account detailed in
this Instruction subject to the safeguards assured by the Direct Debit
Guarantee.
I understand that this instruction may remain with Environment Agency and,
if so, details will be passed electronically to my bank/building society.
Signature(s)
Date (DD/MM/YYYY)
Banks and building societies may not accept Direct Debit instructions for
some types of account.
