THE WHITE EAGLE LODGE
JOINING AS A MEMBER 2016

I would like to support White Eagle’s work and become a Member of The White Eagle Lodge.

Name(s) (in capitals) ………………………………………………………………………………..……………

Address …………………………………………………………………………………………….……………...

…………………………………………. Post Code …………………………. Signature………………………

Email Address (*please see over at foot of page) ……………………………………………………………...

We are warmly grateful for your support and will write shortly to welcome you! If you would like to add a brief personal letter with your application, we are always pleased to have this more personal contact, but this is totally optional. We hope that your closer link with White Eagle’s work is rewarding for you. The form below can be used to become a Member at the subscription rate appropriate for you, though we are always grateful if you are generously wiling to subscribe at a higher rate. Please help us by choosing monthly Direct Debit for your subscription! (Other forms of annual payment are however available; see overleaf), and by signing the Gift Aid Declaration (overleaf), if you are eligible—our sincere thanks for this wonderful help!

I wish to pay as follows

/

Monthly

/

Yearly

/

Monthly

Concession /

Yearly

Concession /

Monthly OR Yearly

Single Member

/

£3.00

/

£36

/

£2.25

/

£27

/ /

*Joint & Family Member

/

£3.50

/

£42

/

£2.75

/

£33

/ /

Yes, I would like to make an additional regular donation (thank you!) of

/ / / / / /
/ / / /

TOTAL

*Joint or Family Membership may include all adults and children living at the same address

By Direct Debit Instructions to your Bank or Building Society to pay by Direct Debit

Originators identification number

6 /

7

/

3

/

2

/

3

/

8

Name and full postal address of your Bank or Building Society

To the Manager Bank or Building Society
Address Post Code

Title Initials Surname

Name of 1st account holder
Name of 2nd account holder
(if applicable)

Sort Code Number Bank or Building Society account No.

Please pay The White Eagle Lodge Direct Debits from the account detailed on this instruction, subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with The White Eagle Lodge and, if so, details will be passed electronically to my Bank or Building Society. Banks or Building Societies may not accept Direct Debit instructions for some types of account. Note to subscriber: debits are normally effected on the 6th of the month.

/ Day / Month / Year
Signature: / Date:

The Direct Debit Guarantee

·  This Guarantee is offered by all Banks and Building Societies that accept instructions to pay Direct Debits.
·  If there are any changes to the amount, date or frequency of your Direct Debit The White Eagle Lodge will notify you 28 working days in advance of your account being debited or as otherwise agreed. If you request The White Eagle Lodge to collect a payment, confirmation of the amount and date will be given to you at the time of the request. / ·  If an error is made in the payment of your Direct Debit by The White Eagle Lodge or your Bank or Building Society you are entitled to a full and immediate refund of the amount paid from your Bank or Building Society. If you receive a refund you are not entitled to, you must pay it back when The White Eagle Lodge asks you to.
·  You can cancel a Direct Debit at any time by simply contacting your Bank or Building Society. Written confirmation may be required. Please also kindly notify us.

Please return to: The White Eagle Lodge, Brewells Lane, Rake, Liss, HANTS, GU33 7HY

Form F12/2016/Issue 10