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 - membership@societyofdorsetmen.co.uk 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 202_ 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.)