Hollinwood Canal Society Application Form
Please complete in block capitals and return to:
HCS Membership, 2 Rock Bank, Stamford Road, Mossley, Lancs. OL5 0BD
I wish to apply for membership of the Hollinwood Canal Society. Rate for associate membership: £6.00 for one year or £15.00 for three years. I support the Aims and Objects of the Society. I agree to my details being kept on a computer for the membership administration only.
space
Title (Mr, Mrs, etc.):
space
 space
Name:
space
space
Address:
space
space
 
space
space
 
space
space
Postcode:
space
 space
Telephone:
space
space
Email address:
space
Please let us know if you change your email address.
space
Signed:
space
 space
Date:
space
space
Subscription:
space
 space
£
space
 space
£6.00 for one year or £15.00 for three years
space
space
Donation:
space
 space
£
space
 space
Thank you
space
space
Total amount:
space
 space
£
space
 Please make cheques payable to "Hollinwood Canal Society" or please consider a standing order (see below).
space
Standing Order Instruction
as an alternative to paying by cheque each year - please return this form to the Hollinwood Canal Society
space
space
To: (name of bank)
space
space
At: (full address of bank)
space
space
 
space
Please pay The Royal Bank of Scotland plc, 118 - 120 Market Street, Droylsden, Manchester, M43 7AA (sort code 16-19-13) for the credit of Hollinwood Canal Society, on the ____________________ (date) the sum of £___________ and the same amount annually until further notice.
space
Please quote (my surname) "_____________________" and debit my (type of account) _____________ account accordingly.
space
space
My bank sort code:    ____  -  ____  -  ____
space
 space
My account number:
space
space
Signed:
space
 space
Name:
space
space
Address:
space
space
 
space
space
Postcode:
space
 space
Date:
space
Please complete this form and return to the Hollinwood Canal Society (see above), who will forward it to your bank.