The Breckland Society - Membership Form

Membership Application/Renewal Form

Please complete in BLOCK CAPITALS and send, enclosing a cheque if applicable, to 
The Treasurer, The Breckland Society
The Old Stables, Hall Farm Barns, Oxborough, Norfolk PE33 9PS

 

 

 

Name

 ___________________________________________________
Address ___________________________________________________
  ___________________________________________________
  ___________________________________________________
Post Code ___________________________
Tel No ___________________________
Email ___________________________
Date of Renewal ___________________________

Membership Category (please tick one)

Adult

£15.00

2 Adults at same address

£25.00

Whilst we would prefer payment by standing order because it reduces our admin costs,
if you wish to pay by cheque please make it payable to The Breckland Society.

I wish to pay by Standing Order
(please complete banker`s instructions below, in BLOCK CAPITALS)

To: Bank

 _______________________________________________
Bank Address _______________________________________________
  _______________________________________________
  _______________________________________________
Post Code ___________________________
   
My Account Name ___________________________
My Account Number ___________________________

Please pay the sum of £         now and £        annually on 1st April until further notice to the account of:

The Breckland Society
Lloyds TSB Bank
38 Market Place,
Dereham,
Norfolk. NR19 2AL

Account No: 1482457
Sort Code: 30-92-88

Signature   __________________________________       Date ______________

 

Please note that members` details will be added to the Society`s database for the sole use of the Society, and the Society undertakes not to pass the information to any third party.