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If you would like to become a Member of
THE BLACK COUNTRY SOCIETY
please print then complete and send to membership Secretary Miss Linda Button
25 Foxhills Park, Netherton, Dudley, DY2 0JQ


Catagory + Subscription Rates
a) Individual £12.50 p.a
b) Groups (Societies/schools) £12.50 p.a
c) Individual + Spouse/Partner £15.00 p.a
e) Overseas - Worldwide £25.00 p.a.

Special first year offer £6.00 for a) and b), £8.50 for c) and £20.00 for d). Payment must be by cheque or contact web editor for possible online payment using Paypal. You must not use Banker's order for this offer


Title: Name/s:

Title:

Name/s:

or Group:

Address:

 

Postcode:

Email:

Telephone Numbers:

Method of payment:


1) By cheque enclosed herewith £.......

2) By Banker's Order Form: see below

Name of Bank: Sort Code:
Address of Bank:
Post Code: Account Number:

PLEASE PAY TO HSBC BANK, Wednesbury Branch, Sort Code 40-19-02 for the credit of

The Black Country Society Account No.41083279 the sum of £.......................... on

(date)........................... and on that day each year until further notice quoting

reference..........................

Signed:................................................................ Date.....................................

Address:

 

Post Code: