Membership Application Form

Name……………………………………………………………………………………………………

Address…………………………………………………………………………………………………

………………………………………………………Post code………………………………………

Telephone……………………Email address…………………………………………………………

I would like to join the Beaconsfield Society and will pay the annual subscription of £10

Signature……………………………………………………….

If possible, please pay by Bankers Order below or alternatively, a cheque made payable to
the Beaconsfield Society.

Bankers Order Mandate — The Beaconsfield Society

To (name and address of your bank):………………………………………………………………

………………………………………………………………………………………………………….

On receipt of this order please cancel any previous Order to the Beaconsfield Society and
pay to Barclay’s Bank plc, 7 Station Parade, Beaconsfield HP9 2PN (Bank Code 20-02-06)
for the credit of The Beaconsfield Society (A/C 80163163) until further notice the annual
sum of £10 commencing on receipt of this Order and the anniversary thereof until further notice and
debit my/our account accordingly.

Sort Code .…./…../….. Account No. ……………………………

Name………………………………………………Signature………………………………………..

Address…………………………………………………………………………………………………

……………………………………………………………………….Postcode………………………

Please copy and complete the form and send to The Treasurer, Silverhurst, Curzon Road, Beaconsfield HP9 2NN and if you are paying by Bankers Order give a signed copy to your bank.

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