GWT Membership Form 05.07.12..pdf - Gwent Wildlife Trust

Gwent Wildlife Trust New Membership or Membership Renewal
Please enter your information and send the form, together with your payment or completed Direct Debit Mandate form, to:
Gwent Wildlife Trust, Seddon House, Dingestow, Monmouth NP25 4DY
T 01600 740600 F 01600 740299 E info@gwentwildlife.org W www.gwentwildlife.org
All subscriptions shown are the minimum payable. Many members pay more, for which the Trust is very grateful.
What can you afford to help look after our local wildlife?
Please select the type of membership you require. If paying by Direct Debit, please complete the Mandate below.
GWT Membership Subscriptions
[ ] Annual Individual (min £24 pa) £..
[ ] Annual Joint (min £30 pa) £..
[ ] Annual Family* (min £36 pa) £..
[ ] Monthly Individual (min £2 pcm) £..
[ ] Monthly Joint (min £2.50 pcm) £..
[ ] Monthly Family* (min £3 pcm) £..
Monthly Payments by Direct Debit Only
(*To include Wildlife Watch, which is the junior section of the trust)
Life membership [ ] £350
Title: Forename: Surname:
Title: Forename: Surname:
Address:
Postal Town:
Postcode:
Tel:
Email:
Gift Aid Declaration: I would like all gifts paid to Gwent Wildlife Trust today and in the future to be Gift Aid donations, enabling GWT to reclaim the tax
until I notify you otherwise. I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is
at least equal to the amount of tax that all the charities or Community Amateur Sports Clubs that I donate to will reclaim on my gifts for that tax year. I
understand that other taxes such as VAT and Council Tax do not qualify. I understand that GWT will reclaim 25p of tax on every £1 that I give.
Signature:
Date:
For family membership please give names and dates of birth (DOB):
Name DOB Name DOB
Name DOB Name DOB
If you have a recruitment or staff code, please enter it here
_____________________________________________________________________________________________________________
Direct Debit Mandate
Gwent Wildlife Trust Seddon House, Dingestow, Monmouth NP25 4DY Tel: 01600 740600
Instruction to your Bank or Building Society to pay by Direct Debit
Bank/Building Society
Reference No (Office Use Only):
R
E
Name of Account:
Sort Code:
--- ---
Account Number:
Please pay Gwent Wildlife Trust Direct Debits from the account
detailed in this instruction, subject to the safeguards assured by the
direct debit guarantee. I understand that this instruction may remain
with Gwent Wildlife Trust and, if so, details will be passed electronically
to my Bank or Building Society.
Signature(s):
Originator’s Identification No:
9 8 5 5 8 2
Date:
Banks and Building Societies may not accept Direct Debit instructions
for some types of accounts.
- - - - - - - - - - - - - - - - - - - - - - - - - -To be retained by the customer - - - - - - - - - - - - - - - - - - - - - - - - - -
Direct Debit: You have pledged to give £. MONTHLY/ANNUALLY (delete as required) to Gwent Wildlife Trust. If paying by Direct Debit, your first
payment will be taken on or after the 18 th of the month following the calendar month in which we receive your application form and on or after the 6 th of the
month thereafter (either monthly or annually).
Data Protection: Gwent Wildlife Trust will keep your details on a confidential database, which will not be shared with any third party. This information will
be used to let you know about the Trust’s work, to maintain your membership records, and to inform you of activities which we think may be of interest to
you.

Direct Debit Guarantee
• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.
• If there are any changes to the amount, date or frequency of your Direct Debit, Gwent Wildlife Trust will notify you 10 working days in advance of your
account being debited or as otherwise agreed. If you request Gwent Wildlife Trust to collect a payment, confirmation of the amount and date will be
given to you at the time of the request.
• If an error is made in the payment of your Direct Debit by Gwent Wildlife Trust or your bank or building society you are entitled to a full and immediate
refund of the amount paid from your bank or building society.
• If you receive a refund you are not entitled to, you must pay it back when Gwent Wildlife Trust asks you to.
• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify
Gwent Wildlife Trust.