Hampshire Branch : Membership Application

I wish to apply for membership in the following category (please tick):

   Individual  (£5 a year):

   Joint  (£8 a year, for 2 people living at the same address):

   Institutional  (£10 a year):

I enclose a cheque/bankers order (please delete as appropriate)

PLEASE COMPLETE IN BLOCK CAPITALS

Name:

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(please state Mr/Mrs/Miss/Ms etc)

Address:

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Postcode:

...............................    Tel No: ..........................................

E-mail:

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Date:

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I am / am not a member of the Jane Austen Society

Please send completed form to Lester Parry, 1 Hadrians Close, Chandlers Ford, Eastleigh, Hampshire SO53 2AS, including either a cheque made payable to The Jane Austen Society (Hampshire Branch) or a completed Bankers Order form (displayed via the above link).

GIFT AID DECLARATION

I declare that I am a UK taxpayer and would like The Jane Austen Society to reclaim tax on this and future payments until further notice.

Signature

Date