THE BROOK GREEN ASSOCIATION

Registered Charity No. 261289

I wish to join/renew my membership of the Brook Green Association:

Name Mr/Mrs/Miss/Ms ………………………………………………………...............................................................

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

………………………………………………................................................................Post Code ………………………

Telephone no. ………………………………………………………………………………….........................................

Email address: ………………………………………………………………………………….......................................

I am interested in (delete as appropriate) and/or I can offer expertise in: Tree Care; Social/Fund Raising Events; Police Liaison; Planning Issues; Street furniture/litter; Distribution (Newsletter etc.)

Subscriptions to the Association may be paid as a Gift Aid donation or with a CAF/GAYE voucher. If you are a tax payer, please complete the Gift Aid declaration at the bottom of this form as well as one of the boxes below.

I wish to take up the "5 for 4" option:          OR I wish to pay for one year only:

Family Membership £28	Family Membership £ 7
Individual £16	Individual £ 4
OAP (per person) £ 8	OAP (per person) £ 2
Business/Organisation £56	Business/Organisation £14

(Cheques and CAF vouchers payable to "Brook Green Association")

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Gift Aid Declaration

I (full name in capitals) ……………………………………………………………………

of (full address)………………………………………………………………………….......

………………………………………………….......……postcode.........................................

I wish that this subscription and all similar regular payments I make hereafter to the Brook Green Association be treated as Gift Aid donations. I confirm that I pay income tax or capital gains tax equal to the tax the Association is able to reclaim and that I will inform the Association should such payments to the Inland Revenue fall below this figure or cease.

Signed ……………………………………………..... Dated ………………………………

Please return this form with your subscription to the Secretary:                       Mrs. A. D. Johnston

22 Phoenix Lodge Mansions, Brook Green, London W6 7BG (7603 6096)  " bgaphoenix@ainsliejohnston.com"