Trust Membership Application Form

 

If you would like to become a member of the Lower Mole Countryside Trust please print off this form and send it with your payment to:
The Treasurer, Lower Mole Countryside Trust, 2 West Park Farmhouse, Horton Country Park, Horton Lane, Epsom, KT19 8PL.

Yes I/We would like to join the Lower Mole Countryside Trust
Type of membership: (please tick)

Individual £10 p.a.

Family £15 p.a.

OAP/student/unwaged* £5 p.a.

Group (club/organisation/council/school)* £15 p.a.

*Delete as applicable
Any additional donation will be appreciated.

Your details:
PLEASE USE CAPITAL LETTERS
Title………………………..Full Name…………………………………………………………………………………………………………
Address……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………….…..Post code…………….………………..………………
Telephone number………………………………………………………
E-mail address…………………………………………………………...
Signature……………………………………………………………………..
Date………………………………………………………………………………

Gift Aid declarations mean the government will give us almost a third extra on top of your membership subscription. Ticking the box below, means that this membership and any future payments you make will qualify. I would like the Lower Mole Countryside Trust to reclaim the tax on any donations or membership subscriptions that I make. I have paid an amount of UK income tax/capital gains tax equal to any tax claimed.

If you would like to pay by Standing Order in future, please tick box and a form will be sent to you.
Payment by standing order reduces our administration costs.

Please do not send cash by post.
Cheques should be made payable to:
Lower Mole Countryside Trust.

Registered Charity No. 1095771
The Lower Mole Countryside Trust is a limited company. Registered in Cardiff.
Company No. 4454401. Registered office as above.