NEW MEMBER / SUBSCRIBER APPLICATION FORM
MEMBERSHIP / SUBSCRIBER CATEGORY - please refer to membership categories on our website and indicate your choice:
Membership / Subscriber category: ______Price: £ ______
CBA Group Membership ______Additional cost: £ ______
Please refer to our website options
University / Institution & course : ________
(applicable to all digital student applicants. NB Must be in full time education, studying for at least 21 hours per week)
Where did you hear about us? ______
______
MEMBER / SUBSCRIBER DETAILS
Title: ______First Name: ______Surname: ______
Delivery address: ______
______Postcode: ______
Telephone no: ______Email Address: ______
______
PAYMENT DETAILS
TOTAL AMOUNT PAYABLE: £______
Please indicate payment method:
Cheque (please make payable to ‘Council for British Archaeology’)
Debit/credit card (please complete details below)
Annual direct debit (please fill in form overleaf)
Monthly direct debit (please fill in form overleaf)
DEBIT / CREDIT CARD PAYMENT
Cardholder name: ______
Cardholder address (if different from delivery address): ______
______Postcode:______
Daytime Tel. number: ______Email Address: ______
Card: / Mastercard / Maestro / Visa /
Card No:
Security number (the last 3 digits on the signature strip) :
Start Date: ____/____ Expiry Date: _____ /_____ Issue Number (Maestro):
IF YOU WISH TO PAY BY DIRECT DEBIT PLEASE COMPLETE THE FOLLOWING FORM, SIGN AND DATE AND RETURN TO THE CBA AT THE ADDRESS BELOW TOGETHER WITH THE RELEVANT APPLICATION FORM (if applicable)
Recipient’s name: ………………………………………………………………………………………………………………………………………………………………
Telephone number: ……………………………………………………... Email: ………………………………………………………………………………………
Recipient’s Address: …………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………...... Postcode: …………………………………………………
Payee’s Name (if different to above): …………………………………………………………………………......
Telephone number: ……………………………………………………… Email: ………………………………………………………………………………………
Payee’s Address (if different to above): ………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….. Postcode: ……………………………………………….
INSTRUCTION TO YOUR UK BANK OR UK BUILDING SOCIETY TO PAY DIRECT DEBITS
Service User Number: Reference – CBA Use Only
- Name and full address of your Bank or Building Society branch
2. Name(s) of account holder(s)
3. Branch sort code
4. Bank or Building Society account number
Return the whole form to:
COUNCIL FOR BRITISH ARCHAEOLOGY
Freepost RTJZ-XXGZ-LUUC, Beatrice De Cardi House, 66 Bootham, YORK, YO30 7BZ
Telephone: 01904 671417 Fax: 01904 671384
(Please note that this is not our postal address and should only be used for renewals)
Email: web:
A Company Limited by Guarantee Registered in England No. 1760254
Registered Charity No. 287815
Patron: HRH The Prince of Wales
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This guarantee should be detached and retained by the payer