Membership Application Form

Please Complete in BLOCK CAPITALS *Delete / Tick as applicable

TITLE: Mr / Mrs / Miss / Ms / Dr * FIRST NAME:

SURNAME:

ADDRESS 1:

ADDRESS 2:

TOWN / CITY:

POSTCODE:

É Please include STD code:

PLEASE ACCEPT MY / OUR* APPLICATION FOR (Please read notes below)

Single Membership Family Membership Senior Citzen / Junior*

£6.00 * £10.00 * £1.00 *

Would you be willing to help in any part of the Group’s activities? (eg: fundraising,

Helping with displays / attending shows, sett monitoring / protection)

Please indicate:

Signature:

Date:

Please make cheques / Postal orders payable to : “Gwent Badger Group”.

If you wish to pay by standing order, please complete the form below.

BANKERS ORDER FORM

TO Bank / Building Society:

ADDRESS:

NAME OF ACCOUNT HOLDER / S:

ACCOUNT NO:

SIGNATURES:

DATE:

Please debit my account on 2 January 200…. and a like amount on the same day each

year until further notice for the sum of £………. (membership amount) and credit:-

“Gwent Badger Group”, Midland Bank, Abergavenny.

Branch No 40-08-04 Account No 11122853

PLEASE RETURN THE COMPLETED FORM / S TO:

Gwent Badger Group,

C/o Mr Tony Croke,

34 Ifton Road,

Rogiet,

Monmouthshire,

NP26 3SS.

The Gwent Badger Group is a registered Charity: No. 507651