At-Bristol Gift Membership Form
RECIPIENTS’ DETAILS: (Please fill in the recipient/s’ details here, listing each person you would like included in the
membership. Please then calculate the price based on the number of people).
1st member: D.O.B. (if child):
2nd member: D.O.B. (if child):
3rd member: D.O.B. (if child):
4th member: D.O.B. (if child):
5th member: D.O.B. (if child):
6th member: D.O.B. (if child):
Daytime telephone: Email:
Individual adult: £35 Individual child: £23 £
Membership joint: £52 (Any 2 people, adult or child, living at the same address) £
Individual adult concession: £27 Individual child concession: £15 £
Concession joint membership: £38 (Any 2 concessions living at the same address) £
Family membership 4: £95 (2 adults and 2 children or 1 adult and 3 children) £
Family membership 5: £110 (2 adults and 3 children or 1 adult and 4 children) £
- 10% if paying by Direct Debit: £
Example: The total price of a membership consisting of two adults and one child would be £75.00.
PAYMENT: (Please tick a box to choose how you would like to pay for the gift membership).
I wish to pay by Direct Debit to qualify for 10% DISCOUNT. I have completed the Direct Debit form overleaf.
I enclose a cheque/postal order for £ _______________ payable to “At-Bristol Ltd”.
I wish to pay by credit/debit card. Please debit my Mastercard/Visa/Switch (delete as appropriate).
Cardholder name ______________________________ Cardholder signature ______________________
Card no. or Switch no. ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___
Start date ___ ___ / ___ ___ Expiry date ___ ___ / ___ ___
Security Code ___ ___ ___ Issue no. (Switch only) ___ ___
YOUR DETAILS: (Please complete your details here. You will receive a gift membership voucher enclosed in a special At-
Bristol greetings card for you to write your own personal message to the recipient/s. The gift membership voucher is then
redeemed by the recipient/s for their new members pack and membership cards at the Information Desk in At-Bristol. The
membership will start from the date the voucher is redeemed and will run for one year or, if you are paying by Direct Debit, as
long as the Direct Debit is in place).
When you have completed the form, please return it with your payment to: At-Bristol Membership, Freepost (SWB578), Bristol BS1 5ZZ.
Instruction to your
Bank or Building Society
to pay by Direct Debit
Please fill in the whole form using a ball point pen and send it to:
Harbourside Originators Identification Number
Bristol 4 0 9 6 1 1
Reference Number (to be completed by At-Bristol)
Name(s) of Account Holder(s)
Instruction to your Bank or Building Society
Please pay At-Bristol Ltd Direct Debits from the account detailed in this
instruction subject to the safeguards assured by the Direct Debit
Bank/Building Society account number Guarantee. I understand that this instruction may remain with At-Bristol
Ltd, and, if so, details will be passed electronically to my Bank/Building
Branch Sort Code
Name and full postal address of your Bank or Building Society
To the Manager Bank/Building Society
Banks and Building Societies may not accept Direct Debit Instructions for some types of accounts
The Direct Debit Guarantee
This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
If there are any changes to the amount, date or frequency of your Direct Debit At-Bristol will notify you 21
working days in advance of your account being debited or as otherwise agreed. If you request At-Bristol to
collect a payment, confirmation of the amount and date will be given to you at the time of the request
If an error is made in the payment of your Direct Debit by At-Bristol or your bank or building society you are
entitled to a full and immediate refund of the amount paid from your bank or building society
If you receive a refund you are not entitled to, you must pay it back when At-Bristol asks you to
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written
confirmation may be required. Please also notify us.