u3a St Austell Membership Application Form

Title: Mr/Mrs/Miss/Ms/Other *

First Name(s) *

Surname *

Home Telephone Number

Mobile Telephone Number

Address: House No. / Name *

Address Street *

Address Town *

Address Postcode *

Email:

will & Gift

Email Consent

I consent to receive U3A communications via email

Emergency Contact Name & Telephone Number: *

Previous Occupation

Optional

Interests

Optional

Skills

Optional

We are interested to know how/where you heard of St Austell u3a e.g. u3a website/u3a member/Friend/Facebook/ Instagram/Twitter

MEMBERSHIP DONATION (FEE) *

I wish to Gift Aid my donation and any donations I make in the future *

For Associate Membership, please confirm u3a where you are currently a member and membership No.

Do you have any special requirements that you would like to inform us about which would enhance your experience?

Optional

I confirm that I will make the appropriate payment via bank transfer *

Payment Made

Bank transfer to: Barclays Premium Business ME account Sort code: 20-30-47 Account Number: 33164489 Account name: St Austell u3a Ref: NEW MEMBER

I apply for membership of St Austell u3a and confirm that I will abide by the terms & conditions of membership. I confirm that I have completed the form myself or have been assisted to do so. I will make full payment of fees due as soon as is reasonably practicable. *

Name

Date *

Dated