APPLICATION FOR MEMBERSHIP/RENEWAL OF MEMBERSHIP
FRIENDS of The IRONBRIDGE GORGE MUSEUM Title & full name I wish to apply for the type of Membership indicated and acknowledge that an amount equal to the Museum’s Annual Passport Ticket will be directly donated to the Museum Trust. Any concession that I receive is solely at the Title & full name discretion of the Ironbridge Gorge Museum Trust. (tick a MEMBERSHIP OPTIONS box) (2nd adult - Family Membership only) FAMILY Admits 2 adults and all your £74.00 children from 5 - 18 years inclusive Number of children (Family Membership only) FAMILY Admits 1 adult and all your £63.00 Address children from 5 - 18 years inclusive ADULT Admits member plus one £58.00 connected person Postcode ADULT SINGLE Admits member only £45.50 Tel No. 60 PLUS Admits member plus one £50.00 connected person Signature 60 PLUS SINGLE Admits member only £40.50
VOLUNTARY DONATION £ Date
EMAIL ADDRESS You may use my details to contact me (tick a box) YES NO The Ironbridge Gorge Museum Trust would like to keep in touch with you about museum events, special offers and new developments. Please provide your email address below if you wish to receive this information. We will not sell, distribute or lease your personal information to third parties and you can opt out at any time. For further information on how to opt out see our terms and conditions on www.ironbridge.org.uk
FRIENDS of The IRONBRIDGE GORGE MUSEUMS Title first name/initials GIFT AID DECLARATION Surname If you are a UK taxpayer, the value of your donation can increase by 25% under the Gift Aid Scheme at no extra cost to you. Please complete and Address sign the declaration to confirm that you are a UK taxpayer and would like the Friends of Ironbridge Gorge Museum (FIGM) to claim Gift Aid on your past, present and future donations. In order to Gift Aid your donation YOU MUST TICK THE BOX BELOW: Postcode I want to Gift Aid my donation of £ and any donations I make in the future or have made in the past 4 years to The Friends of the Date Ironbridge Gorge Museum. I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference. Please notify the charity if you: want to cancel this declaration, change your name or home address, no longer pay sufficient tax on your income and/or capital gains.
FOR OFFICE MEMBERSHIP TYPE AMOUNT USE ONLY NUMBER
Instruction to your Bank or Building Society to pay by Direct Debit
FRIENDS of The IRONBRIDGE GORGE MUSEUMS
Please fill in the whole of this form in ball point pen and return, with the above forms to: Friends Administrator, The Ironbridge Gorge Museums, Coalbrookdale, Telford, Shropshire TF8 7DQ
Name(s) of account holder(s) Originator’s Identification Number 9 3 0 5 6 6
Bank or Building Society Account Number Reference No. (for office use only)
Branch Sort Code Instruction to your Bank or Building Society Please pay the Friends of the Ironbridge Gorge Museum annually the sum of £ ...... from the account detailed in this instruction, subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with the Friends of The Ironbridge Gorge Museum and if so, details will be passed electronically to my Name and full postal address of your Bank or Building Society Bank or Building Society. To: The Manager Signature(s) Bank Address
Date Postcode Banks and Building Societies may not accept Direct Debit Instructions for some types of account.
The Direct Debit Guarantee l This guarantee is offered by all Banks and Building Societies that accept instructions to pay by Direct Debits l If there are any changes to the amount, date or frequency of our Direct Debit The Ironbridge Gorge Museum Trust will notify you 14 working days in advance of your account being debited or as otherwise agreed. If you request The Ironbridge Gorge Museum Trust to collect a payment, confirmation of the amount and date will be given to you at the time of request. l If an error is made in the payment of your Direct Debit by The Ironbridge Gorge Museum Trust 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 The Ironbridge Gorge Museum Trust asks you to). l 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.