New Members Application Form
.....................................
Please complete this form together with the Standing Order Form and send it to
Peter Lush, Membership Secretary, 25 Maumbury Square, Dorchester DT1 1TY
Telephone - 01305 260039
Email - peterlush3@hotmail.com
Annual subscriptions for Members are due on 1st October each year and are collected by
Standing Order only. New Life Members should send a cheque made payable to
“The Society of Dorset Men”
Please enrol me as:
[ ] A Life Member £200
[ ] A Member £15 per annum
(tick one)
Title Mr/Dr/Rev/Other……………….Surname……………………
.
…………………...Date…………………
First Name
(s)…………………………………………………………….
...............................................................
Address
.....................................................................................................................................................................
...................................................................................................................................................................................
Post/Zip code
.............................................
Telephone
..........................................................................................
Email:
......................................................................................................................................................................
I am associated with the Dorset Town or
Parish of ………………………………………………………
.......
By Birth, Descent, Marriage, Property, Other (
Delete those that do not apply)
.
Do you object to the Society holding your membership record on computer
.......................
YES/NO
Introduced by
.........................................................................................................................................................
………………………………………………………………………………………………………………………
Standing Order Form
To
................................................................................
Bank Plc
…………..
.......................................................................
Branch
Address
............................................................................................................................
Postcode
...........................
Sort Code
......................................................
Account No
.....................................................................................
Account Name(s)
......................................................................................................................................................
Please pay
HSBC Plc,
18 St Mary Street, Weymouth, Dorset DT4 8PH Sort code
40-46-23
for the
credit of the
“Society of Dorset Men”
Account Number
21182226
the Sum of £
15-00
(fifteen
pounds) commencing
IMMEDIATELY
and then annually from
1st October 20
until you
receive further notice from me in writing and debit my/our account accordingly.
Signed
........................................................................................................................
Dated
...................................
Name (In BLOCK CAPITALS please)
..................................................................................................................
Please quote the reference
........................................................................
(
for completion by Membership Sec
.)