Membership Form - Black Country Society

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: