I Wish to Support Fulham Palace by Becoming a Patron (Please Select)

Fulham Palace Patron Registration Form

Name *......

Address* ......

Postcode*......

Telephone ......

Email......

I wish to support Fulham Palace by becoming a Patron (please select):

Patron£300 per annum ( )

Joint Patrons£500 per annum( )

A minimum payment of £60 per person (including VAT) secures all Annual Patron benefits. The balance of £240 for Individual Patrons and £380 for Joint Patrons is a suggested donation to which gift aid provisions apply, but you may purchase the benefits package separately without making any further donation.

Life Patrons£3,000 single payment( )

Joint Life Patrons£5,000 single payment( )

A minimum payment of £600 per person (including VAT) secures all Life Patron benefits over a period of 10 years. The balance of £2400 for Individual Life Patrons and £3800 for Joint Life Patrons is a suggested donation to which gift aid provisions apply, but you may purchase the benefits package separately without making any further donation.

( ) I enclose a cheque for £…………………… made payable to ‘Fulham Palace Trust’

( ) I will make a BACS transfer of £………………….

( ) I will/have set up a direct debit via PayPal/Standing Order (please circle)

If you would like to set up a standing order please complete the reverse of this form.

Account name: Fulham Palace Trust; Bank: CAF Bank; Sort code: 40-52-40; Acc number: 00003631

( ) Please treat as Gift Aid donations all qualifying gifts of money made to Fulham Palace Trust (registered

charity number 1140088) today, in the past 4 years, and in the future.

I confirm that I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference. I have read the declaration above which is relevant to my membership.

Signature ...... Date......

Please notify Fulham Palace Trust if you wish to cancel or change this declaration.

*Data Protection

I would like to receive the Supporters’ newsletter ( ) by email / ( ) by post

I would like to receive exclusive emails to members with details of upcoming events for members and Fulham Palace’s fundraising campaigns ( )

Your personal data will not be shared or used by any other organisation other than Fulham Palace Trust.

Please return to Clare Maddison, Development Office, Fulham Palace, Bishop’s Avenue, LONDON, SW6 6EA

Thank you for supporting Fulham Palace

Fulham Palace Patrons

Standing Order Form

Instructions to your bank to pay by Standing Order:

Name of Bank/Building Society:
Address of Bank:
Postcode:

Please pay to the account of Fulham Palace Trust:

CAF Bank Ltd, 25 Kings Hill Avenue, Kings Hill, West Malling, Kent, ME19 4JQ

Sort Code 40-52-40, Account Number 00003631 the sum of:

£ on the day of (month) (year)

and continue to make the same payment MONTHLY ANNUALLY until further notice

(please circle).

(NB: the date of the first payment should be at least one month from today’s date.)

Your Account Number

Sort Code

Name:

Address:

Postcode:

Signature:

Date:

NOTE TO PAYING BANK: PLEASE QUOTE REFERENCE:

Please return this form to:

Development Office, Fulham Palace Trust, Fulham Palace, Bishop’s Avenue, Fulham, London, SW6 6EA Registered Charity No: 1140088

Tel: 020 7751 2437; Email: