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The Philip Larkin Society Membership Application 2004

I wish to apply for membership of the Philip Larkin Society

name
  
address
  
 
 
postcode
  
country
  
phone
  
fax
  
email
  
membership
FULL £18
  
unwaged £12
  
student £4
     please tick one box
  I would like to make an additional, voluntary donation of £________ to the society  
Cheques should be made payable to 'The Philip Larkin Society'. We accept payment by sterling, US dollar or euro cheques or sterling cash. We cannot accept foreign cash because of the prohibitive cost of conversion. The exchange rate for cheques is:

  
   
£ sterling
US $
Euro €
  
full fee
18
33
26
unwaged
12
22
18
student
4
8
6
  I want the Philip Larkin Society to treat all subscriptions and donations I make to the Society from the date of this Declaration, until I notify you otherwise, as Gift Aid Donations. I declare that I am a UK taxpayer.
(Delete if not appropriate)
signed date    

Return to: Andrew Eastwood, 16 Mere View Avenue, Hornsea, East Yorkshire, HU18 1RR, England

form version 17.01.2004