Subscription Renewal Form

Payment Method: Cheque Direct Debit: Annually Monthly Phone to pay by card £25 annually or Annual Membership £2.30 per month

Life Membership – at least £300, as a one off payment

You can help people with CMT in the UK even more by making an extra donation:

One-off donation – Many thanks for your generosity £………………………………

Monthly donation to add to your direct debit £……………………………… per month

Cheques payable to CMT United Kingdom* Cheque enclosed for £………………………………

I want to Gift Aid my donations above. I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference. I will undertake to notify Charcot-Marie-Tooth UK if I no longer pay sufficient tax on my income, if I want to cancel this declaration or if I change my name or address.

Signed ………………………………………………………………………….……………… Date ………………………………….…………

Your Details

Title: Last Name:

Preferred First Name:

Address:

Telephone Number Postcode: (inc code) Email address:

Date of Birth: Type of CMT (If known)

Please tick here if you would like to receive our “E-ComMenT” regularly, and to receive ComMenT via the website only, saving us money on postage.

*bank account is still in the name of CMT United Kingdom

Charcot-Marie-Tooth UK Instruction to your bank or building society to pay by Direct Debit Please fill in the whole form including official use box using a ball point pen and send it to: Service User Number (SUN)

Charcot-Marie-Tooth UK* 2 5 0 6 0 8 3 Groveley Road Christchurch FOR PSL re CMT United Kingdom OFFICIAL USE ONLY This is not part of the instruction to your Bank or Building Society. BH23 3HB Important – Please complete these details:

Account Holder(s) Name & Address:

Name(s) of Account Holder(s) Name:

Address:

Bank/Building Society account number Postcode:

Email Address:

Branch Sort Code Instruction to your bank or building society Please pay PSL re CMT United Kingdom* Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain Name and full postal address of your Bank or Building Society with PSL re CMT United Kingdom* and, if so, details will be passed To: The Manager Bank/Building Society electronically to my bank/building society.

Address Signature(s)

Postcode Date

Reference Number  Bank account remains in the name of CMT United Kingdom.

Banks and Building Societies may not accept Direct Debit Instructions for some types of account

DDI1

This guarantee should be detached and retained by the Payer.

The Direct Debit Guarantee

 This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.  If there are any changes to the amount, date or frequency of your Direct Debit PSL re CMT United Kingdom will notify you 5 working days in advance of your account being debited or as otherwise agreed. If you request PSL re CMT United Kingdom to collect a payment, confirmation of the amount and date will be given to you at the time of the request.  If an error is made in the payment of your Direct Debit, by PSL re CMT United Kingdom or your bank or building Society, you are entitled to a full and immediate refund of the amount paid from your bank or building society - If you receive a refund you are not entitled to, you must pay it back when PSL re CMT United Kingdom asks you to  You can cancel a Direct Debit at any time by simply contacting your bank or building Society. Written confirmation may be required. Please also notify us.