PLEASE COMPLETE IN BLOCK CAPITALS

Name:

....................................................................................................

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

Address:

....................................................................................................

....................................................................................................

....................................................................................................

....................................................................................................

Postcode:

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

E-mail:

....................................................................................................

Date:

.....................................................

(a) I enclose a cheque / banker's order form / sterling draft for £...............

(b) I wish to pay by credit card (Master Card / Visa Card / Switch Card)

Credit card number.............../.............../.............../...............

Expiry date........../..........

Issue Number...................

Name on Card..............................................................

Reference number (final 3 digits of security number on reverse of card)..............................

GIFT AID DECLARATION

I declare that I am a UK taxpayer and would like the Society to reclaim tax on all my subscriptions and donations until further notice.

Signature..............................................................................    Date..................................