The Breckland Society - Membership Form

Please:
• print out using button at right;
• complete form IN BLOCK CAPITALS;
• send to the address below, enclosing
your cheque/postal order if applicable.

To: The Breckland Society
The Hay Barn
Hall Farm Barns
Oxborough
Norfolk PE33 9PS

Name
Address
		Town/City
County		Post Code
Tel		Fax
Email

Membership Category (please tick one):

Adult Ł15 Joint Ł25 Young person Ł8 Life Membership Ł150
(If you require Corporate or Educational Membership, please contact the Secretary.)

I would like to pay by (please tick one): Cheque Postal Order

and enclose payment of Ł (payable to The Breckland Society)

or by Standing Order (please complete Banker's standing order instruction below):

To: (Bank Name & Address)

My Account Name:

My Account Number:

Please pay the sum of Ł now and Ł
annually on April 5th until further notice to the account of
The Breckland Society at Lloyds TSB Bank, 38 Market Place, Dereham NR19 2AT.
Account Number: 1482457 Sort Code: 30-92-88

Signature: Date: / /

To: (Bank Name & Address)


My Account Name:
My Account Number:
Please pay the sum of Ł now and Ł annually on April 5th until further notice to the account of The Breckland Society at Lloyds TSB Bank, 38 Market Place, Dereham NR19 2AT. Account Number: 1482457 Sort Code: 30-92-88
Signature: Date: / /