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MEMBERSHIP APPLICATION FORM

Registered Charity No 238005

Please PRINT this form and complete it, together with the Gift Aid Declaration, in BLOCK CAPITALS then return to:

The Finance Officer, The Council of Christians and Jews, 5th Floor, Camelford House, 87-89 Albert Embankment, London SE1 7TP

I wish to be a member of the CCJ Hillingdon Branch YES / NO

SUBSCRIPTIONS

Single	per year £17.00
Couples	per year £25.00
Students	per year £6.00
Corporate	per year £50.00

Payment by cheque made payable to the Council of Christians & Jews

I enclose £....................as my subscription to become a member of the Council of Christians & Jews

To pay by Bankers Order, please print out the separate Bankers Order Form

Payment by credit or debit card (please tick box)

Please debit my:
Visa [ ] MasterCard [ ] Amex [ ] Visa Delta [ ] Switch [ ] Solo [ ]
Switch/Solo Issue No [ ] [ ]
Security Number (last three digits on your card's signature strip) ................

Issue Date [ ] [ ] / [ ] [ ] Expiry Date [ ] [ ] / [ ] [ ]

Card No.

| | | | | | | | | | | | | | | | | | | |

Name (as it appears on card).....................................

Subscription Amount: £................

Signature:...................................... Date:.............

Name:.................................................

Address:............................................................................

............................................................................

Postcode:................... Tel.No:........................

E-mail:......................................@......................................

I have read the Code of Practice and agree to abide by it.

Signature:...................................... Date:......................................

GIFT AID DECLARATION

PLEASE COMPLETE THE FOLLOWING IN ADDITION TO THE ABOVE

Please treat my donations to CCJ, as detailed below, as Gift Aid donations (please tick as appropriate)

[ ] the enclosed donation of £............
[ ] all donations I make from the date of this donation and until I notify you otherwise.

Details of Donor:

Title................... Forename(s):............................................

Surname:...........................................

Address:............................................................................ Postcode:...................

Signature:...................................... Date:......................................

Please note:
• You must be a UK tax payer and pay tax equal to or more than the tax deducted from the subscription/donation.
• You can cancel this agreement at any time by writing to us, but whilst the deduction is in force, you must notify us of any changes in your name and address.

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