Membership Application Form: print it; complete it; sign it; attach your cheque; send it in!
I apply for membership of LUPUS UK
Title: Mr. Ms. Mrs ................... First name .........................................................
Surname:...................................................................................................
Address:...................................................................................................
...........................................................................................................
...........................................................................................................
Postcode: ............................................ Tel:................................................
| Membership fee | £____________ |
| (plus donation if wished, thank you) | £____________ |
| TOTAL | £____________ |
Annual Rates: Single membership £10 pa; Double membership** £15 pa; Single overseas membership £14 pa; Double overseas membership** £19 pa [**both at same address]/
GIFT AID DECLARATION
I wish LUPUS UK to treat any membership fees / donations made by myself as Gift Aid donations. I confirm I pay an amount of income tax and/or capital gains tax at least equal to the tax that the charity reclaims on my donations in the tax year
Signature..........................................................................................
Date......................................................
Send this form and your cheque to:
LUPUS UK, St James House, Eastern Road, Romford, Essex, RM1 3NH
Systemic Lupus Erythematosus - hard to say, harder to live with.