THE JANE AUSTEN SOCIETY

Registered Charity No. 1040613

Membership Application Form 2018

I wish to join the Society  /  I wish to renew my membership     (Please indicate)

Subscription Rates

Annual Subscription

Mrs Sharron Bassett

UK

£28.00

Joint Rate

£33.00

'Sospiri'

Overseas

£38.00

Joint Rate

£43.00

9 George Street

Student

£12.00

Dunfermline

(for each year up to 3: UK and Ireland)

Fife KY11 4TQ

Corporate

£50.00

sharronbassett@hotmail.co.uk

Subscription Payment Methods: Cash, Cheque, Bank Standing Order, Credit Card.

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GIFT AID DECLARATION

*I want the Society to reclaim tax on all subscriptions and donations I have made since 6 April 2000, and on   all donations and subscriptions I make from the date of this Declaration until I notify you otherwise.
*I declare that I am a taxpayer and I have paid an amount of tax that at least equals the tax deducted from   any such subscription or donation.
*I agree that I shall advise the Treasurer of the Society or any other named officer should I cease to be a   United Kingdom tax payer.

Full Name:.............................................................................................................

Signature:........................................................................Date:.............................     Reg. Charity No. 1040613

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ANNUAL MEMBERSHIP

PLEASE PRINT

Title: Prof. Dr. Mr. Mrs. Ms...............


First Name:......................................................Surname:................................................................
Address:..........................................................................................................................................
.............................................................................................................Postcode:...........................
Phone No:.....................................................E-mail:.....................................................................................
I enclose a cheque for: £........... payable to The Jane Austen Society/I wish to pay £............ by Mastercard/
Visa number:................../................../................../..................   Expires:........../..........
Authorisation code: (last 3 nos. beneath signature on reverse)..................Switch card/Issue No: ..................
My membership number is:.............................. (current members)

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BANKER'S ORDER

To: (Name of Bank)................................................................................. Date ......................................
Address of Bank:.....................................................................................................................................
Postcode of Bank:........................ Account number:.........................  Sort code: ........... .......... ..........
(Please give name and address of your own Bank, and your account number)
Please pay to the Jane Austen Society, at Lloyd's Bank plc, 40 High Street, Alton, Hampshire GU34 1BQ
(Account number 01330528, Code 30-90-15) the sum of ........... on* ......................... and continue paying
that amount annually until further orders in writing from me. This cancels all existing orders in favour of the Society.

Signature .........................................................................................

Full name .........................................................................................
Address .............................................................................................................................
...................................................................... Post code ............................................
Membership number ...........................................(provided by office)

Return to: Sharron Bassett, 'Sospiri', 9 George Street, Dunfermline, Fife, Scotland KY11 4TQ
* Please check that you have filled in the commencement date.