Membership Form
Membership Form for new members, or renewal of subscription, for the year starting 1 April 2011

Please complete in BLOCK CAPITALS

Title: - Mr., Mrs., Miss, Ms., Dr., (or Other ………….) please circle as appropriate.

Surname ……………………………………… First Name …………………………………..

Address ………………………………………..............................................................

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Post Code..........................................

Telephone ……………………………........... Email …………………………………...

Membership Category: Individual / Family - please circle as appropriate
If you choose Family Membership, please name the other person to be covered by that membership

Surname (Mr, Mrs, Miss, Ms, Dr, (or Other ……)…………………… First Name …………………………

Annual Subscription:

Individual Member …………………………… ……… £5.00

Family Member (2 adults based at same address) ..……. £7.50

Cheques payable to 'SPJARA'. Please return form to
Jonathan Moffitt, 35 Gratton Road, Cheltenham, Gloucestershire GL50 2BT

Membership Category:…………………. Paid: £…………………….

* Please indicate if you would be interested in becoming a member of the Committee

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ST PHILIP & ST JAMES (LECKHAMPTON) AREA RESIDENTS' ASSOCIATION

Receipt

Received the sum of £ …………………..

Date: ……………………………………

Signed: ……………………………..................................(Treasurer)