| Please print and complete this form and send it to: | Membership |
| The Old Birkonian Society | |
| 58 Beresford Road | |
| Birkenhead | |
| Merseyside CH43 2JD |
Please enrol me as an Annual member of the Old Birkonian Society - I have completed the Standing Order below to cover the membership cost of £9.00 per annum.
| Title | Initials | Surname | "Known" forename |
| Honours and Awards (Only Honours bestowed by the Sovereign, University Degrees and principal professional qualifications) |
| Occupation |
| Postal Address, incl postcode | Telephone No |
| For OBS use only | |
| Date of Birth | Dates at School | Email Address |
| If you would like details of the London Branch of the OB Society, please tick here |
| Signature: | Date: |
| Standing Order
Mandate Please use BLOCK CAPITAL LETTERS throughout Bank address
|
Please pay Barclays Bank, Liverpool City Office (20-51-01) for the credit of the The Old Birkonian Society, account number 90671754 the sum of £9.00 (NINE POUNDS) UPON RECEIPT OF THIS ORDER and thereafter on the 10th January every year until you receive further notice from me/us in writing and debit my/our account accordingly. |
| Account Name to be
Debited Account Number to be Debited |
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| Signature(s) Date |
