MEMBERSHIP REGISTRATION FORM
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Your Title (Mr, Miss, Dr etc) (*)
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Your Name (*)
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For joint memberships give the name of the second member
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Address 1 (*)
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Address 2 (*)
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Address 3
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Address 4
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Email address (*)
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Telephone (*)
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Choose a USERNAME for the website (*)
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Choose a PASSWORD for the website - please note that new users are added to the system manually so your username and password may not be effective for a few days. We'll let you know when we've done it. (*)
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Tell us about any special interest you have in the Mortimers or medieval history
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I am happy for my name and areas of interest to be included in a list of members in the members-only section of the website - your email address will not be displayed (*)
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Gift Aid - UK Taxpayers only
I wish to Gift Aid all donations made in 2017 and in the future to the Mortimer History Society (registered charity 1171392), I am a UK taxpayer and understand that if I pay less Income Tax or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that year, it is my responsibility to pay the difference. (*)



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How do you intend to pay your subscription?
It reduces our administration (and makes it simpler for you) if you set up a standing order. You can do this via Paypal if you have a Paypal account. If you would like to set up a standing order with your bank, choose that option and we'll send you a form to make it simple.







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Please state the letters in this image (*) Please state the letters in this image
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