Application form for Membership of DNHAS

Please print off this form, fill it in by hand in block letters, and post it to us at

Dorset County Museum
High West Street
Dorchester, Dorset
DT1 1XA
telephone (01305) 262735

Please complete part 1, part 2 (the Direct Debit Authority), and if you are a taxpayer, part 3 (the Gift Aid Declaration).
The Dorset Natural History and Archaeological Society is a company registered in England and Wales No. 3362107 and registered as a Charity No. 1062400.

Part 1: Application for membership
Type of membership desired: please mark one only. Subscription rates correct for 2008
	Full	£32.00
	Joint	£43.00	(2 members at one address)
	Associate	£21.50	(no Proceedings)
	Student	£8.50
	Museum Club	£7.50	(under 16)
	Patron	£155.00
	Other classes of membership on application
Name
Address
Postcode
Telephone number
E-mail address
Date of birth	day month year (if under 16)
Special interests
Signed
Date	day month year

Part 2: Instruction to your bank or building society to pay direct debits

Originator's identification number

Name of account holder(s)

Bank or Building Society account number

Branch sort code (from top right corner of your cheque)

To the Manager,

name of your bank or building society branch

full postal address

postcode

reference number

Please pay to the Dorset Natural History and Archaeological Society Direct Debits from the account detailed on this instruction, subject to the safeguards assured by the Direct Debit Guarantee.

Signed

Date

day month year

for DNHAS use only

Part 3: Gift Aid declaration
Please consider signing a Gift Aid Declaration if you pay Income Tax. As the Society is a registered charity, we can reclaim tax of nearly 28% of your subscription from the Inland Revenue. This costs you no more and increases substantially the value of your payment to the Society. When you make a Gift Aid Declaration, please complete the Direct Debit form. The Declaration must be dated on or before the first payment.
I, (full name in capitals)
of (address)
(postcode)
request the Dorset Natural History and Archaeological Society to treat the membership subscription and all donations I make on or after the date of this declaration as Gift Aid donations.
Signed
Date	day month year
Notes 1: You must pay an amount of income tax or capital gains tax equal to the tax we reclaim on your donations. Please remember to notify us if you no longer pay an amount of tax or capital gains tax equal to the tax we reclaim on your donations. 2: If you wish to cancel this declaration at any time please do so in writing.