‘100,000 Club’

Membership Form

 

Name________________________________________________________________________

Organisation (if applicable)   ____________________________________________________

Address______________________________________________________________________

_____________________________________________________________________________

Postcode: _____________________________

Tel__________________________________________________________________________

E-Mail _______________________________________________________________________

You can pay by Direct Debit from only £ 8.33 per month – see following page for Direct Debit mandate

 

Please debit my credit card £

(Visa / MasterCard / Delta / Solo / Switch please delete as appropriate)

            Card Number __________________________________________________________________

            Expiry Date ___________/__________

            Issue Number (Switch only) ________

I enclose a cheque payable to ‘The UK Coalition’ for £

Please invoice me for £             at the above address

           Gift Aid Declaration (Please tick below if you would like us to claim back 28p in the pound from the government on your donation - £28 in this case, and it will cost you absolutely nothing extra. Gift Aid however is only applicable to individuals and cannot be made by an Organisation. However organisations can increase their subscription to £128 to compensate for this.)

              I am a UK taxpayer and want the UKC to reclaim tax on my donation. [ yes/no ]

              All personal information will be covered by the Data Protection Act and will remain strictly confidential. The UKC (UK Coalition of People Living with HIV and AIDS) will only access details for matters concerning the DoUKCare Campaign and the work of the UKC. Funds raised will go directly to support the DoUKCare ‘100,000 Club’ Fund.

Upon completion of your registration, you will receive the following:

A certificate of membership to the ‘100,000 Club’

A year’s subscription to Positive Nation magazine

The opportunity to attend the UKC Hero Award ceremony

What name would you like to appear on your membership certificate?

______________________________________________________________________

Return signed form to UKC, 250 Kennington Lane, London SE11 5RD

100000 Club            Direct Debit Mandate

	Donation details I would like to pay £ __________to become a member of the UKC DOUKCare? 100000 Club. Please accept this authority to take 12 equal monthly payments from my bank account, details of which are below. [     ] I wish to Gift Aid this amount – If you are a UK taxpayer for every pound you give we get an extra 28p from the Inland Revenue. So tick here it’s that simple. [     ]  Please tick here to confirm that you are a UK taxpayer Please return fully completed form to : UKC, 250 Kennington Lane, London SE11 5RD
	Personal details Title _______ First Name ________________ Last name ________________ Address _______________________________________________________               ________________________________ Post Code ______________ Tel No _______________________ e-mail ___________________________