Please print and use these forms

PSA  Prostate Cancer Support Association

                  CANTERBURY  BRANCH                    

MEMBERSHIP APPLICATION

                                                                                                                                                                                  Reg Charity No 1067253

1	Surname and Title (Mr, Mrs, Ms. Rev. etc)
2	First Name
3	Address Line 1
4	Address Line 2
5	Address Line 3
6	Town
7	County
8	Postcode
9	Telephone No.
10	Fax No.
11	E-mail
12	Date of Birth
13	Partner’s First Name
14	Partner’s Surname (If different)

 

PSA  Membership costs £12 p.a. (or £1.00 for each full remaining month of the current year) payable on joining and thereafter on 1st January.  (For those with low incomes the membership fee is £3 p.a. or 25p for each full remaining month of the current year).

 

Joining membership fee              £

Voluntary donation                        £________

Total                                                £________

 I will pay by Bankers Order and have completed the form below

 I enclose a Cheque/Postal Order payable to “PSA Prostate Cancer Support Association”

 I have completed the Gift Aid Declaration below

 

I apply for membership of PSA and undertake to treat all information regarding members and former members of PSA as strictly confidential now and at all future times. I agree that the personal information, provided by me may be stored in a computer on a confidential basis in accordance with the Data Protection Act.

 

Signed                                                                                              Date        

 

Please  return the whole of this form to the address below.

PLEASE DO NOT SEND THE BANKERS ORDER DIRECT TO YOUR BANK.

------------------------------------------------------------------------------------------------------------------------------------

GIFT AID DECLARATION

Mr/Mrs/Miss/Ms..…….Initials …………

Surname…...…………………………….

Address…………………………….…….

…………………………………………….

………………..….Postcode …...………

Please tick the red box below so we can claim back 28p for every £1 you give.   Thank you

  I would like The Prostate Cancer Support Association to claim back the tax on all donations made by me from 6 April 2000 until further notice.

In order to validate your declaration, please enter today’s date here …..../…………./……..

Please remember to tell us if you change your address or no longer pay enough tax to cover the money we claim back from the Inland Revenue.