EASTERN COUNTIES DACHSHUND ASSOCIATION

Application For Membership/Standing Order Form

1) Your Name & Address (BLOCK CAPITALS PLEASE)
 
 
 

Postcode:

Tel:

[ ] Tick if you do not wish to have your name & address held on computer (to assist mailing)

2) NEW MEMBERS ONLY: I wish to become a member & am sponsored by:

a) Mr/Mrs/Ms Signed

b) Mr/Mrs/Ms Signed

3) EITHER enclose your Membership Subscription

OR complete the Standing Order Form opposite.

[ ] I enclose £5.00 Single Membership

[ ] I enclose £5.00 Joint Membership

[ ] I wish to pay by Standing Order

4) Details of your Breed(s):

  

[ ] Smooth [ ] Long [ ] Wire

[ ] Min/Smooth [ ] Min/Long

[ ] Min/Wire

Your Affix:
   
Date: Signed:

Please return this half of the Form to the Secretary:

Ian J Seath, "Sunsong", 204 Blind Lane,

Flackwell Heath, High Wycombe. HP10 9LE

If you wish to pay by Standing Order,

complete the Form below and send it to your Bank/Building Society.

EASTERN COUNTIES DACHSHUND ASSOCIATION

Please set up a Standing Order payable to

The Eastern Counties Dachshund Association, as detailed below.

Your Name & Address (BLOCK CAPITALS PLEASE)
 
 
 

Postcode:

Tel:

This instruction cancels any previous Standing Order.

Details of your Bank/Building Society Account:

Your Account Sort Code (e.g. 40-25-67)

  

Your Account Number (to be debited)

  
Please pay to the Account of Eastern Counties Dachshund Association, the sum of...
£5.00 (Five Pounds: Joint or Single Membership)
...and subsequently on the 1st January each year until cancelled by me in writing.

Eastern Counties Dachshund Association Account to be credited:

Barclays Bank Plc, Flackwell Heath Branch, PO Box 41, High Wycombe, HP11 2BG

Account No. 60204668, Sort Code 20-40-71
Date: Signed:

Please return this half of the Form to your Bank/Building Society