(PLEASE PRINT)

Title______________ Name       ___________________________________

Address       ___________________________________________________

____________________________  Post Code       ____________________

Telephone______________    email     ______________________________

Hobbies/Interests      ____________________________________________

How did you hear about us?____________________________________

I agree to this information being stored manually or on a computer for U3A use only.  U3A will not pass this information to any other organisation without your permission.

SIGNED_______________________        DATE         _________________

I enclose payment of the sum of £12.00 p.a., for the year commencing January 1^st 2008, or £6.00 from July. (Fee of £9.50, or £3.50 from July, if a copy of current membership card from another U3A is attached)

£____________

Cheques should be made payable to:  Weymouth & Portland U3A

and sent to:

R. Gill, 4 Brookside Close, Preston, Weymouth, Dorset DT3 6DW

GIFT AID DECLARATION – Charities can reclaim tax on subscriptions/donations under the Gift Aid Scheme.  You must be a UK taxpayer and have paid in the last tax year income or capital gains tax at least equal to the tax we reclaim.  Your declaration can be cancelled at any time if your circumstances change.

I am a UK taxpayer, and wish the tax to be reclaimed on this and all future subscriptions/donations I make to Weymouth & Portland U3A.

SIGNED___________________________  DATE:__________________

RENEWAL    or     NEW MEMBERSHIP     (Circle as appropriate)