THE JOHN HAMPDEN SOCIETY

MEMBERSHIP APPLICATION FORM

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I/We wish to apply for membership of The John Hampden Society.

Surname(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forename(s) . . . . . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode . . . . . . . . . . . . . . . . . . . . . .
Telephone No (include STD code). . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . .

British Isles Overseas
Adult membership .................................................. £10.00 £12.50    
Under-18 membership (Date of birth.........................) £5.00 £7.00    
Joint membership (give both names) ............................ £15.00 £18.00    
Family membership (give all names) .............................. £24.00 £30.00    

I/We enclose a cheque/postal order for £ .......... as a donation to the society (optional)
(please tick the appropriate box)
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STANDING ORDER AUTHORITY

To:-The Manager              
 
 
 
 
Please write the name and full
postal address of your bank in this box
Name(s) of account holder(s) . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . Postcode . . . . . . . . . . .

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


Account No.                                             
Bank sort code             --           --          
Please insert your bank account details in this box

I/We instruct you to pay the above account the sum of £ . . . . . . . . (in figures) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (in words) now and on the 1st of January annually until further notice to THE JOHN HAMPDEN SOCIETY (Sort code/account no. 30-91-60 - 03935099 ) at Lloyds TSB Bank plc, 49 High Street, CANTERBURY, Kent CT1 2SE.

(If completing this mandate as an existing member delete the words now and above. The Standing Order will then come into affect on the 1st January following.)


If you are a UK taxpayer please complete
the Society's gift-aid form
and return it to us with your application form.

Please send the completed form(s) Standing Order & Gift Aid and any additional remittance to:

The Membership Secretary
The John Hampden Society
Treminnis, Barteliver Hill
Grampound
TRURO, Cornwall TR2 4SA.
E-mail