Butterfly Conservation Membership Application Form

PERSONAL DETAILS    (block capitals please) Title Forename Surname Your Address Postcode Email address Telephone number Date of birth (if under 21) If you are joining as a Standard Member please give the names of any children (aged under 21) living with you and to be included in your membership. Date of birth First name Surname

PLEASE TICK MEMBERSHIP CATEGORY REQUIRED   Total   Standard membership Includes one or two adults and their children living at the same address and membership of the local Branch £ 24-00 a year Young Person For anyone under 21 years of age who is not included in a standard membership (see above). Includes membership of the local Branch £ 12-00 a year Life Benefactor Includes life membership of the local Branch £ 1000-00 European Membership £ 24-00 a year Overseas Membership £ 26-00 a year Donation towards urgent butterfly and moth conservation Total

Butterfly Conservation Membership Application Form

METHOD OF PAYMENT    (tick one box) Direct Debit – please print the Direct Debit Guarantee form and return it, completed, together with this Application Form. Cheque/PO (made payable to "Butterfly Conservation") Please debit my Mastercard / Visa Card   Card number   Expiry date

PLEASE SIGN AND DATE Cardholder's signature Date Cardholder's address (if different from above)

From time to time we would like the opportunity to contact you with relevant information about our work. However, if you would prefer not to receive this information, please tick the box below. I do not wish to receive information about the work of Butterfly Conservation.	When complete please return this form to The British Butterfly Conservation Society Ltd. Manor Yard, East Lulworth Wareham, Dorset  BH20 5QP
	For Office Use Only