BLAKE SOCIETY MEMBERSHIP FORM

							BLAKE SOCIETY MEMBERSHIP FORM
Please return to: The Blake Society, St James’s Church, 197 Piccadilly, London, W1J 9LL, UK
I would like to become a member/renew my membership (please delete as applicable) of the Blake
Society with the following membership (please tick box)

  waged - £20 a year
  student / unwaged - £10 a year

Please tick appropriate box

  I enclose a cheque payable to THE BLAKE SOCIETY




Title______ First Name ___________________Surname_______________________________

Address_____________________________________________________________________

____________________________________________________________________________

____________________________________Postcode_________________________________

Telephone__________________ Email ____________________________________________



If you are eligible, please also complete the Gift Aid declaration below.


GIFT AID (you can do this whether paying by cheque or standing order)
Make your subscription go further. If you pay income tax or capital gains in the UK, giving through Gift
Aid will enable us to claim back tax at the basic rate from HMRC. Please tick box.

 I am eligible as a UK taxpayer and consent to the Blake Society claiming Gift Aid on all qualifying
subscriptions and donations since 6 April 2004 and from the date of this declaration until I notify you
otherwise. OR  I am not eligible as a UK taxpayer/do not consent.


Signature_________________________Date________________________________________



 Gift Aid notes: 1. You must pay an amount of UK income tax and/or capital gains tax at least equal to the tax
 that the Blake Society reclaim on your subscriptions and donations in the tax year. If in the future your
 circumstances change and you are no longer a UK taxpayer you should cancel your declaration. Please notify the
 Blake Society if you change your name or address. You can cancel the Gift Aid declaration at any time by notifying
 the Blake Society. Our reference number for HMRC is XR84173