Associate Membership Application Form
2016-17
Please tick the correct option:
.... Mr .... Mrs .... Ms .... Other (please specify) ......................
Name ........................................................................................
Address
..................................................................................................
..................................................................................................
Phone..................................... Post code ..................................
e-mail address ..........................................................................
Associate Membership:
.... Full £15.00 .... Pensioner/student/unwaged £12.50
Cheque for £.................. enclosed, payable to ‘Cheltenham and Gloucester Branch of the Historical Association’. (NB The name of the account has not yet been changed.)
If you need a receipt, please enclose a stamped addressed envelope and tick here: ....
If you would like details of national membership, please tick here: ....
Please send this form with your cheque to:
Robert Sutton, 9 Tom Price Close, Cheltenham GL52 2LE