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Individual Membership Application Form

First Name:
Last name:
Female:		Date of Birth:
Male:
Address:
Town/City:
Post Code:
Tel No.:
Email:
Youth Work Employer :
Job Title:
Work Address:
Post Code:
Town/City:
Payment Method:
Annual Cheque:		Please make cheque for £75/£105* payable to AMAZE
Standing Order:		Please complete the form below
		* I would like to joinf CYWU at an additional discounted rate of £30
I apply to join AMAZE and agree to pay the annual membership fee:
SIGNED:
Date:
	Official use only: Membership number
STANDING ORDER AUTHORITY
Name and address of your bank
Post code:
Sort code:		- -
Account number:
Account name:
Your full name and address
Post code:
Please pay AMAZE, HSBC 1 Great Cornbow, Halesowen, West Midlands, B63 3AD.
Sort code 40-23-03 Account number: 51682369 the sum of
£
Amount in words
Starting on
and thereafter on the same day each month/year* until further notice
			* please delete as appropriate
SIGNED:
Return form to:		AMAZE PO Box 12064
		Halesowen B63 3ZN
	Official use only: Please quote reference:
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