PSA Prostate Cancer Support Association

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MEMBERSHIP APPLICATION
Reg Charity No 1067253 - BLOCK CAPITALS PLEASE

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.
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GIFT AID DECLARATION
Mr/Mrs/Miss/Ms..…….Initials …………
Surname…...…………………………….
Address…………………………….…….
…………………………………………….
………………..….Postcode …...………

Please tick the 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.
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BANKERS ORDER - BLOCK CAPITALS PLEASE

Please pay PSA Prostate Cancer Support Association the sum of £………………..
(Amount in words) ……………………………….………………………………………
on receipt of this order
AND £12 a year thereafter on 1 January

To The Manager (Name of your Bank)…………………………………………..……….
Address ………………………………………………………………………..…………….
…………………………………...……….Postcode…………Sort Code           -           -

Please credit the above sum(s) to PSA Prostate Cancer Support Association
Account No 02781183 at Alliance & Leicester plc, Bootle, Merseyside GIR 0AA
Sort Code No 72-00-06, quoting Reference No (for office use only) ……………………….
Debiting my account number .................................................
This instruction is to continue until cancelled by me in writing.

Signature                                                                     Date

Mr/Mrs/Miss/Ms ……. Initials……...Surname………………………………..…………..
Address…………………………………...……………………………………………..…...
…………………………………………………………………………..Postcode…………
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PLEASE SEND TO : Membership Secretary, PSA Prostate Cancer Support Association, BM Box 9434, London WC1N 3XX