HEART CONCERN
                                             Lancaster, Morecambe and District
                                                     Heart Support Group
                                                 (Reg. Charity No. 701746)
                                   Please Print out & return form with payment of £2.00 to Treasurer                   
                                   Mrs S. Hannigan, 3 Wartonwood View Carnforth LA5 9DE

Name:................................................................Membership No..........................................

May I confirm my details as follows:

Address:......................................................................................................

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Telephone numbed :….........…..........

I enclose:                   My £2.00 subscription for 2004 - 2005 [due on or before 2 Jan 200]
  [Tick  boxes
  as appropriate]          I pay by banker's order on……............…............date)
                              
                                 Additional donation of £...............
   
 Signed:………………………………………………….Date: .………………….
   
 Fax \ e-mail:…………….......….....................................................