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Gift membership form 2009.10

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Gift membership form 2009.10 Powered By Docstoc
					G i f t M e M b e r s h i p ApplicAtion forM
1. nEW MEMBER dETAIlS
Title
Adult 1 Adult 2 Address
Adult Adult plus children 2 Adults 2 Adults plus children £39 £44 £69 £74 £30 £35 £53 £58

2. MEMBERSHIP CATEGORY (Tick category required)
Date of Birth
ANNUAL MEMBERSHIP Price Tick Adults: Aged 16-59. Children Aged 5-15 under 5’s free Concessions: 1 or both of the following: over 60, full time students, anyone in receipt of state benefit, Young Scot card holders, disabled. Senior Life: Over 60 For joint memberships, all membership information will be sent to one nominated address.

First Name Surname

Postcode E-mail FAMILY MEMBERS AGED 5-15 First Name Child 1 Child 2 Child 3

Telephone (daytime)

Concession Concession plus children 2 Concessions

Surname

Date of Birth

2 Concessions plus children

LIFE MEMBERSHIP (Direct Debit not available for life memberships) Single Life (1 card) Joint Life (2 cards) Senior Life (over 60 1 card) Joint Senior Life (over 60 2 cards) £1,000 £1,300 £650 £800

3. GIfT MEMBERSHIP
Your details (giver). Complete new member (recipient) details at section 1 above.

4. METHOd Of PAYMEnT
Surname Membership fees (from section 2) £

Title Address

Initials

Gift memberships from section 3; Friends 20% discount on annual memberships only £ Donation £ £ TOTAL DUE

Postcode

Telephone (daytime)

I am a Friend of Historic Scotland No Yes Membership no. (Existing Members only - deduct 20% on prices above for annual gift membership Not available by Direct Debit)

Direct Debit Cheque Credit/debit card

Complete Direct Debit instruction below Pay ”Historic Scotland” Complete details below Maestro/Mastercard /Visa /Delta Issue No:

Send the gift pack to:

my home address direct to the recipient include message gift recipient

In future years send the renewal notice to: me Message

Valid from

Expires end

3 digit code

Any other instructions

Cardholder name Cardholder signature Date

5. Data Protection: If you do not wish to receive information from any other Historic Scotland department other than Membership, please tick the boxes. Your details will not be passed to any other organisation. by email by post

Please fill in the whole form using a ballpoint pen and send it to: Historic Scotland, Longmore House, Salisbury Place, Edinburgh EH9 1SH 1. Name and full postal address of your Bank or Building Society branch To: The Manager

InSTRuCTIOn TO YOuR BAnk OR BuIldInG SOCIETY TO PAY BY dIRECT dEBIT.
Originators Identification Number

9 0 0 4 5 5

Bank or Building Society Address

5. Historic Scotland reference (office use only) 6. Instruction to your Bank or Building Society
Please pay Historic Scotland Direct Debits from the account detailed in this Instruction subject to the safeguards assured by The Direct Debit Guarantee. I understand that this instruction may remain with Historic Scotland and, if so, details will be passed electronically to my Bank/Building Society

Postcode 2. Name(s) of account holder(s) 3. Branch sort code
(from the top right hand corner of your cheque)

Signature(s)

Date Banks and Building Societies may not accept Direct Debit Instructions for some types of account.

4. Bank or Building Society account number


				
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posted:12/27/2009
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