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					Genetic Alliance UK Membership Renewal Form 2012-2013
Deadline for renewals is 31st March 2012
You can also complete this form online at www.geneticalliance.org.uk/membershiprenewal.htm
Organisation Details
Name of Organisation:
Address:-




Post code:
Telephone:
Email:
Organisations Gross Income:
Registered charity:
Charity number:
State type of organisation:

Details Of Main Contact
Title:                                   First name:
Surname:
Please ensure that all information is correct as we may need to verify your membership eligibility.
                               ORGANISATION INCOME                      MEMBERSHIP              Please tick only
                 BAND
                                 (Per Annum (p.a.))                      FEE (p.a)                  one box
                    B             £5,001 - £25,000                         £55
                    C              £25,001 - £100,000                         £95
                    D             £100,001 - £250,000                        £190
                    E             £250,001 - £500,000                        £320
                    F             £500,001 - £1 Million                      £600
                   G             £1,000,001 - £5 Million                     £900
                    H            £5 Million - £10 Million                   £1,250
                    J           £10 Million - £50 Million                   £2,450
                    *           £50 Million - £100 Million                  £6,850
                    *          £100 Million - £150 Million                 £12,000
                    *                  £150 Million +                      £17,750

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Genetic Alliance UK: Unit 4D, Leroy House, 436 Essex Road, London, N1 3QP
                     020 7704 3141         mail@geneticalliance.org.uk    www.geneticalliance.org.uk

Charity registered in England and Wales (no. 1114195) and in Scotland (no. SC039299)
Company limited by guarantee, registration no: 05772999
Payment Options
  Payment Type                Please tick one
                                   box
        BACS

       PayPal

       Cheque


BACS/Standing Order
Bank Details:               CAF Bank Ltd
                            PO Box 289, West Malling, Kent, ME19 4TA
Account No:                 00009426
Sort Code:                  40-52-40
Ref:                        Genetic Alliance UK & (Organisation name)
IBAN Code:                  GB48 MIDL 4005 3072 1385 49
Swift Code:                 MIDLGB 2141W

PayPal**
Payment can also be made on the Genetic Alliance UK website via ‘PayPal’.
Go to www.geneticalliance.org.uk and Select ‘Join Us’.
Enter membership band (B-J), contact name and organisation name then proceed to PayPal
login and payment. Please ensure your membership application is sent via post or e-mail.

       **You will have to have an account wit h ‘PayPal’ to make this payment.
 Setting up a ‘PayPal’ account is very easy to do, please go to www.paypal.co.uk to
                                        sign up.
Cheque
Please make cheques payable to ‘Genetic Alliance UK’.
Once payment has been received a remittance advice will be dispatched.


Please return this completed form before 31st March 2012 either via email to
Julian@geneticalliance.org.uk

Or post it to us at:
Freepost RRAR-SZJE-YSTU
Genetic Alliance UK
Unit 4D, Leroy House,
436 Essex Road,
London,
N1 3QP

Page | 2

Genetic Alliance UK: Unit 4D, Leroy House, 436 Essex Road, London, N1 3QP
                     020 7704 3141         mail@geneticalliance.org.uk    www.geneticalliance.org.uk

Charity registered in England and Wales (no. 1114195) and in Scotland (no. SC039299)
Company limited by guarantee, registration no: 05772999

				
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