Lapal Canal Trust : Membership Application Form

Please print A4 and send by Post to the
Membership Secretary

Ray Jones

Tel : 01564 772 155 email : membership@lapal.org

Please fill-in or tick any section which relates to your application.

Mr Ray Jones,
Membership Secretary
Lapal Canal Trust
77, Widney Road,
Knowle, Solihull,
West Midlands, B93 9EA

I/We wish to join the Lapal Canal Trust in the indicated category;

Individual Annual : £ 10	Individual 10-years : £ 90
Family Annual : £ 15	Family 10-years : £ 135
OAP Annual : £ 5	OAP 10-years : £ 45

I/We wish to make an additional donation of : £ ___________
A cheque (made payable to the Lapal Canal Trust) is enclosed for the total sum of : £ ___________

Applicant :	Mr, Mrs, Miss, Ms other _________	Forename(s);	Surname;
Spouse / Partner :	Mr, Mrs, Miss, Ms other _________	Forename(s);	Surname;
Children's Names :	1	2	3
Postal Address :	.
	.
	.
	Postcode :
	(Country if not UK) :

Telephones :	Home;	Work;	Mobile;
E-mail :

My/Our main interest(s) lies with the :

Entire Lapal Canal

Western (Halesowen) Projects

Lapal Tunnel / Woodgate Valley OTT Canal

Eastern (Birmingham) Projects

My/Our interest stems from one or more of these aspects :

Angling	Boating	Conservation	Environmental
History / Heritage	Walking / Jogging / Cycling	Waterways Network	Wildlife

I/We might like to become actively involved in : ______________________________________
Please continue over the page; e.g. if you wish to declare your Profession / Expertise / Affiliation in relation to the Trust's activities and needs.

I/We understand that the Lapal Canal Trust holds Membership details in accordance with the Data Protection Act, 1998 and will process it only for its own organisational purposes.

I/We direct The Lapal Canal Trust, a registered charity, to treat all donations including membership subscriptions, which I/we have made since 6th April 2000 and all donations which I/we make from this declaration, as "Gift Aid Donations". * Please delete this statement if you are not a UK taxpayer or do not wish your donations to be treated this way.

I/We agree to be bound by the provisions of the Memorandum and Articles of Association (copy available on request).

Signature :

______________________________________

Date :

___________________

The Lapal Canal Trust is a registered charity (1013845) and a non-profit distributing company limited by guarantee, registered in England (2721675)


For LCT use : PJB/WWW/IPR/05/10	Date Received	M/Ship Card No.	Date Card Sent