Please print and complete this form and send it to: David Rule
The Old Birkonian Society
58 Beresford Road
Birkenhead
Merseyside CH43 2JD

Please enrol me as a Life Member of the Old Birkonian Society - I enclose a cheque payable to the Old Birkonian Society for the appropriate amount, based on the table at the bottom of this form.

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: 

Life Membership of the Society is available at the following rates, dependant on age:

Under 30
£100
51 - 60
£45
30 - 40
£75
61 - 70
£30
41 - 50
£60
Over 70
£15

 

 

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