Anglo Ecuadorian Society

THE ANGLO ECUADORIAN SOCIETY
www.angloecuadorian.org.uk

Please print and complete the following page:

To: The Hon. Treasurer
The Anglo Ecuadorian Society
29 Chantry Hurst
Epsom, Surrey KT19 7BW

MEMBERSHIP FORM

Subscriptions are due on 1st January each year [delete as appropriate]

1. I/We would like to join the Anglo Ecuadorian Society and enclose my/our cheque for £ …… as my/our subscription for the year 200…. [new members joining after 30th June pay half the subscription].

2. I/We enclose my/our cheque for £ …… as my/our renewed subscription for the year 200….

3. I have completed the attached Bankers Order so that my subscription for the year 200.… and subsequent years may be paid by Standing Order.

Subscription Rates are as follows:

Full Time Student Membership £ 5.00 per annum
Individual Membership £10.00 per annum
Couples Membership £15.00 per annum
Corporate Membership £40.00 per annum

Name: ………………………………… Date: ……………..

Address: ……………………………………………………………………

Post Code: ………………………… Telephone: ……………………….

EMAIL ADDRESS: …………………………………………………………………...

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BANKERS ORDER

To: ………………………………………………………… [your Bankers]

Address: …………………………………………………………

………………………………………………………….

Please Pay to: Lloyds Bank plc, 8-10 Waterloo Place, London SW1Y 4BE [Sort Code No. 30-00-08] for the account number 3757368, The Anglo Ecuadorian Society, the sum of £ …… with immediate effect and subsequently on the 1st day of January annually until further notice, asking them to quote my/our name as reference.

My Account Number: ……………………………………………….

Signature: ……………………………………………….

Name [Block Letters] ………………………………………………..

Address: ………………………………………………..

Date: ………………………………………………..