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

| Name | | ||
| Address | | ||
| Town/City | |||
| County | Post Code | ||
| Tel | Fax | ||
Adult £15
Joint £25
Young person £8
Life Membership £150 ![]()
(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 £
(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 £ 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: |