MEMBERSHIP FORM

To
Mr Glynn Nixon
Copper Beeches
Knapp Lane
Painswick
Stroud, GL6 6YE

I/We* apply for membership of Stroud and District U3A and enclose £15.00/£28.00* subscription fee (Cheque or PO payable to Stroud and District U3A) and a stamped addressed C5 envelope (approx 9"x6") for membership material. I understand and agree that information provided will be used for U3A purposes only.

Surname
(Mr/Mrs/Miss/Ms)..............................................................and*(Mr/Mrs/Miss/Ms)......................................................

First Name..............................................................................and*..........................................................................................

Address........................................................................................................................

........................................................................................................................................

........................................................................................................................................

Post Code................................................Tel...............................................................

Email address(es)......................................................................................................................................................

and*....................................................................................................................................................

Signature:........................................................................... Date:.......................................

* Delete if not applicable

We would be grateful if you would also complete the Gift Aid form