Britannia Panopticon Supporter’s Application Form
YES: I would like to donate and become/renew as a Supporter of the Friends of Britannia Panopticon Music Hall Trust (SCIO) at the following subscription level: (Please tick box)
Annual Supporter (£20 per annum)£______
Life Supporter (£250)£______
Life Supporter over 65 (£150)£______
Additional Donation£______
I would also like to become/renew as a Subscribing Member (£1 per annum)£______
TOTAL£______
Payment can be made by cheque/ postal payable to “The Friends of Britannia Panopticon Music Hall Trust (SCIO) and post to us at 117 Trongate, Glasgow G1 5HD or by BACS to: Cooperative Bank, Sort Code 08-92-99, Account Number 65833157 (Account name: Friends of Britannia Panopticon MH Trust.)
Title: ______First name: ______Surname: ______
Address:______
Town: ______Postcode: ______
Telephone:______Mobile: ______
Email: ______Membership No (if renewing) ______
Date: ______Signed: ______
CHARITY GIFT AID: Boost your donation by 25p of Gift Aid for every £1 you donate.
In order to Gift Aid your donation you must tick or cross this box: ☐
I want to Gift Aid my supporter’s donation using my details as above and any donations I make in the future or have made in the past 4 years to: The Friends of the Britannia Panopticon Music Hall Trust (SCIO) Charity Number SC029031.I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference.
Please let us know if you want to cancel this declaration, change your name or home address or no longer pay sufficient tax on your income and/or capital gains. If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code.
DATA PROTECTION
The Friends of Britannia Panopticon Music Hall Trust (SCIO) would like to retain your contact details from this form on a computer database for the duration of your subscription.
Please opt in to enable us to use your contact detailsfor the following by ticking or crossing the boxes below:
To contact me by post☐
To contact me by email ☐
To contact me by phone ☐
To administer my subscription information☐
To claim Gift Aid☐
To invite me to donate to Britannia Panopticon fund-raising campaigns ☐
To send me newsletters☐
To send menotices of events and shows☐
To opt out from any of these uses at any-time email
SIGNED:______