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					Office use only: CA /   DD / CC      / CH         £                       Cheque No                                    Date


                                                                                                                    Suite 3, Broadway House,
                                                                                                                      149-151 St Neots Road
                                                                                                                                   Hardwick,
                                                                                                                         Cambridge CB23 7QJ
                                                                                                                      Tel/Fax: 01954 212468
                                                                                                                     Email: admin@ita.org.uk
                                                                                                                    Website: www.ita.org.uk


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                                 2012/2013 MEMBERSHIP RENEWAL – CONTRACTUAL TRAINEE

Renewal of your ITA membership is now due for the membership year 2012-2013. Please complete the form and
return with your payment/instruction by 1st October 2012. Membership renewals received after 31st December
2012 will be subject to a £20 surcharge for late payment.

Members who are ITA Registered may have their contact details published in the ITA Register online and issued to
enquirers through the ITA office. Full policy is on the ITA website. Please confirm on the enclosed form which details
you want to be published.

Contractual Trainee Membership - Contractual Trainee Members who have completed their TA training and are
UKCP Registered Therapeutic Counsellors or BACP accredited counsellors may qualify for TA Practitioner membership.

ITA Membership fee including EATA Subscription paying by Direct Debit                       £138.00
ITA Membership fee including EATA Subscription paying by BACS, Cheque, Credit or Debit Card £158.00

If you have paid your EATA subscription via another organisation your ITA membership will be;

ITA Membership fee excluding EATA Subscription paying by Direct Debit                       £114.00
ITA Membership fee excluding EATA Subscription paying by BACS, Cheque, Credit or Debit Card £134.00

Name of organisation.__________________________________________________________

To receive the Transactional Analyst in print (price per annum)                                                           £ 20.00

All members will receive the Transactional Analyst quarterly by e-mail as a large attachment. Please make sure you
supply a valid e-mail address and add “admin@ita.org.uk” to your email address book to prevent emails ending up in
the spam/junk email folder of your system

Bursary Donation:

I would like to donate to the ITA bursary fund £10  £15  £20  £…. 
(tick the box next to the amount you would like to donate)

I have included this amount within my cheque / I am paying by Direct Debit or Credit Card and would like the above
amount added to my payment. (Please delete what does NOT apply)

          Member Organisation of the United Kingdom Council for Psychotherapy. Affiliated to the European Association for Transactional Analysis.
Registered in England Company No. 3364220. Reg. Charity No. 1062624. Registered Office: George Court, Bartholomews Walk, Ely, Cambridgeshire CB7 4JW
Payment:

Direct Debit – Final deadline for mandate & renewal form to be received is 1st October 2012

Direct Debit transactions will take place on or shortly after the following dates: 19th October 2012, 21st November
2012, 21st December 2012, 19th January 2013 and 20th February 2013. To pay your ITA membership this way please
complete the enclosed Direct Debit mandate and send with your completed renewal form.

It must be sent by post with original signature(s) and must reach the ITA office no later than 1st October 2012.
Mandates received after the deadline cannot be processed so will be returned. You can pay by 1 or 5 instalments. If
you pay by 1 instalment it will be taken on the first transaction date.

I have enclosed the Direct Debit mandate and wish to pay by 1                         or 5      instalments.

Payment by cheque

Please make your cheque payable to ITA Only and send with this form to the above address by 1st October 2012

Payment by Credit/Debit Card
Please note: There is a 2.5% surcharge fee if you are paying by Credit Card. Debit Cards are free.
Please enter details below & return to the above address by 1st October 2012

Visa Credit         Master Card             Visa Debit          Maestro (UK only)                     Amount £ __________

Card No.: __ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __ / __ __

Issue no. ____ Start date __ __ / __ __ Expiry: __ __ / __ __

CSC (last 3 digits from back)         __ __ __

Name on Card: _____________________ House Number __________ Post Code: _______________


On Line Banking - Remember to Quote your membership number as a reference

The Royal Bank of Scotland
Account No              : 10024689
Sort Code               : 16 00 23
Account Name            : Institute of Transactional Analysis
Date of Transfer              :____________________________




          Member Organisation of the United Kingdom Council for Psychotherapy. Affiliated to the European Association for Transactional Analysis.
Registered in England Company No. 3364220. Reg. Charity No. 1062624. Registered Office: George Court, Bartholomews Walk, Ely, Cambridgeshire CB7 4JW

				
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