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