Please print this form out, fill in the relevant details, and send with your subscription to:-
Mrs J. Emery, 118. Coulsdon Road, Coulsdon, Surrey, CR5 2LB
Standing Order Form
To the Manager
__________________________________________
Insert above the name of your Bank or Building Society current account
Address___________________________________
__________________________________________
__________________________________________
Full address of your Bank or Building Society branch
My account number-________________________
Insert here the 8-digit right-most number at the bottom of your cheques
Name (As on cheques. Block letters please
________________________________
Please pay on the 5th January 20.........next and then each subsequent year on the same date, the sum of £10 (ten pounds) from the above account to the credit of
THE BOURNE SOCIETY
Account 96721089
Girobank plc, Bootle, Lancashire,
GIR 0AA
Sort code 72-60-04
This standing order supersedes and cancels any previous standing order made by me in favour of the Bourne Society
Signed___________________________
Date________/________/________
Note to member: Please return this form to
118 Coulsdon Road, Coulsdon, Surrey, CR5 2LB
Not to your bank
Note to bank: Please quote_________________
when making payment
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Application for Membership of
Information will be stored on computer but will not be divulged outside the society
Full Name__________________________Title____
Full names of others in household to be included as members (No additional cost)
__________________________________________
Address___________________________________
__________________________________________
__________________________________________
Postcode______________
Telephone_________________________________
Where did you hear about the Bourne Society
_________________________________________
It would help us put like-minded people in touch with each other if you would state briefly your particular local history interests by circling from the list, and add anything else below:-
Architecture, Railways, Trams, Photography,
Ecology, Conservation, Churches, Streets,
Maps, Hedges, Boundaries, Artifacts,
Fields & Farms, Industry, WW1, WW2,
House History, Local Personalities,
Ancient History
Signature_________________________________
Date_______/_______/_______
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