Holst Birthplace Museum - Members Application Form

Holst Birthplace Trust Membership Application Form

I/We would like to join the Holst Birthplace Trust

NAME:

________________________________

ADDRESS:

________________________________

POSTCODE: _______________

TELEPHONE:

________________________________

EMAIL:______________________________

Membership Options (Tick Your Choice)

MEMBERSHIP TYPE	ANNUAL	LIFE
Single	£15	£250

Joint	£20	£350

Family	£25	-

Overseas	£25	-

Corporate	£50	£500

Benefactor	£60	£1000

Joint or Family Benefactor	£100	£1500

Corporate Benefactor	£300	-

I/We enclose a cheque payable to the Holst Birthplace Trust

£________ as a fee for ______________________ Membership

Gift Aid: I/We wish my/our payments to the Holst Birthplace Trust to be treated as Gift Aid Donations.
I/We expect to pay an amount of income tax at least equal to the tax the charity reclaims on my/our behalf

Signature: _______________________________________ DATE ___ | ___|___

Data protection: Will be used by the Holst Birthplace Museum for the despatch of newsletters and other information. Your details will not be shared or sold to third parties.

I/We Prefer to pay by Standing Order

To the Manager

_____________________________________ plc

Address:

________________________________

Name(s) of Account Holder(s) : ________________________________

Branch Sort Code: ________________________________

Account Number: ________________________________

Please pay to the credit of the Holst Birthplace Trust
Account No. 11851012 at HSBC Bank, 2 The Promenade, Cheltenham, GL50 1LS (Sort Code 40 - 17 -10)

The Sum of £_____________ now and on the ____ of October next and on the same day annually until further notice.

Signature: _______________________________________ DATE ___ | ___|___

PLEASE PRINT AND MAIL THIS FORM TO:
The Membership Secretary
Holst Birthplace Museum, 4 Clarence Road, Cheltenham, GL52 2AY