Please refer to the Terms & Conditions of Patron membership () before completing this form.

Name(s) …………………………………………………………………………………………………………………

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

……………………………………………………………………………… Postcode …………………………………….

Tel……………………………………………………... (Home) …………………………………………………. (Mobile)

Email (1st member)………………………………………………………………………………………………………………………..

Email (2nd member)……………………………………………………………………………………………………………..

I wish to support Fulham Palace by renewing my Patron membership (please select):

Patron£300 per annum ( ) Life Patrons£3,000 single payment( )

Joint Patrons£500 per annum( ) Joint Life Patrons£5,000 single payment( )

A minimum payment of £60 per person (including VAT) secures all Annual Patron benefits. The balance of £240 for Individual Patrons and £380 for Joint Patrons is a suggested donation to which gift aid provisions apply, but you may purchase the benefits package separately without making any further donation.

A minimum payment of £600 per person (including VAT) secures all Life Patron benefits over a period of 10 years. The balance of £2400 for Individual Life Patrons and £3800 for Joint Life Patrons is a suggested donation to which gift aid provisions apply, but you may purchase the benefits package separately without making any further donation.

( ) I enclose a cheque for £…………………… made payable to ‘Fulham Palace Trust’

( ) I will make a BACS transfer of £………………….

( ) I will/have set up a direct debit via PayPal/Standing Order (please circle)

If you would like to set up a standing order please complete the reverse of this form.

Account name: Fulham Palace Trust; Bank: CAF Bank; Sort code: 40-52-40; Acc number: 00003631

( ) Please treat as Gift Aid donations all qualifying gifts of money made to Fulham Palace Trust (registered

charity number 1140088) today, in the past 4 years, and in the future.

I confirm that I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference. I have read the declaration above which is relevant to my membership.

Signature ...... Date......

Please notify Fulham Palace Trust if you wish to cancel or change this declaration.

My communication preferences: / Email (1st member) / Email (2nd member)
I would prefer to receive the bi-annual Supporters’ newsletter by: / post / email / post / email

The details you supply will be used for administering your membership, claiming Gift Aid if applicable and other purposes as detailed in the Terms & Conditions of your Patron membership. Your personal data is safe with us; we will not share it with any third parties other than with our ticketing and membership partners for the purpose of delivering your membership. Your details will never be sold to or swapped with any third party. Full details of how we look after our supporters’ data are available in our privacy policy on our website at

Please sign and return this form to the Development Office, Fulham Palace, Bishop’s Avenue, London SW6 6EA.

I/we have read the updated terms and conditions of my/our membership with Fulham Palace as detailed on the website with and I/we will be happy to proceed with the membership contract.

Signature (1st member) ……………………………...... Date …………………………………

Signature (2nd member)..…………………………...... Date …………………………………

Fulham Palace Patrons

Standing Order Form

Instructions to your bank to pay by Standing Order:

Name of Bank/Building Society:
Address of Bank:
Postcode:

Please pay to the account of Fulham Palace Trust:

CAF Bank Ltd, 25 Kings Hill Avenue, Kings Hill, West Malling, Kent, ME19 4JQ

Sort Code 40-52-40, Account Number 00003631 the sum of:

£ on the day of (month) (year)

and continue to make the same payment MONTHLY ANNUALLY until further notice

(please circle).

(NB: the date of the first payment should be at least one month from today’s date.)

Your Account Number

Sort Code

Name:

Address:

Postcode:

Signature:

Date:

NOTE TO PAYING BANK: PLEASE QUOTE REFERENCE:

Please return this form to:

Development Office, Fulham Palace Trust, Fulham Palace, Bishop’s Avenue, Fulham, London, SW6 6EA Registered Charity No: 1140088

Tel: 020 7751 2437; Email: