CHIPPENHAM CIVIC SOCIETY MEMBERSHIP FORM

Send £11 (minimum annual subscription for either single or joint membership in one household) or £6 (student) or £14 (corporate) to Roger Backway, The Beeches, Old Hardenhuish Lane, Chippenham, Wiltshire SN14  6HH. Cheques should be made payable to Chippenham Civic Society.

I/We wish to join Chippenham Civic Society and enclose herewith the membership fee.

SURNAME(Mr/Mrs/Miss/Ms)…………………………………………………..

First name……………………..

Joint member If applicable                                                                                                

SURNAME(Mr/Mrs/Miss/Ms)………………………………………………….

First name……………………

ADDRESS……………………………………………………………………

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Post code………………………………….

Telephone no................................Email...................................................................

Membership fee enclosed  £…………………       (Minimum £11/£6/£14)

GIFT AID DECLARATION

I want Chippenham Civic Society (Registered Charity No 268087) to reclaim tax on my subscription and any donations I may make. I understand that I must pay an amount of income tax or capital gains tax in the relevant tax year equal to any tax reclaimed by Chippenham Civic Society in that period. I confirm that I am a UK tax payer, resident in the UK for tax purposes.

Signed……………………………………..

Date……………………………………….

Please print name……………………………………………