Membership Form

Surname at school: _____________________________ First name: ____________________________

Current name: ________________________________ Date of Birth: ___________________________

Address: _____________________________________________________________________________

_____________________________________________________________________________________

Telephone: ___________________________ email: __________________________________________

Dates at School: ________________________________ House: ________________________________

Oldfelder: __________ Pupil or Staff: ___________ Married SGS pupil: ________________________

Additional information: _____________________________________________________________________________________

The subscription is £10 a year, payable on 1^st January, or you may opt for Life Membership for a one-off payment of £75. The Swan magazine, produced most years, is free to members. The Association uses excess funds to support reunions and to support charity organisations working with children in the Purbeck area and abroad. If you wish to give additional sums to support this work, please indicate below.

Subscription £10 Life membership £75

Donation ____ Donation ___

Total £___ Total £___

Please return this section to Malcolm Batt, Membership Secretary, with a cheque if you have opted for Life membership, and send the section below to your Bank if you have opted for Annual subscription. ======================================================================

Instructions to Bank.

(This instruction supersedes any previous instruction in favour of Swanage Grammar School Association)

To: (Name of your bank) ____________________________________________________ Sort Code: _______________

Address: _________________________________________________________

Please pay to: Swanage Grammar School Association

At: LloydsTSB Bank Ltd, Bridgewater, Somerset

Sort Code: 30-91-20

Account number: 0007193

Quoting reference (insert your school surname & initials) __________________________________________________________,

The sum of £___ (__________ pounds) immediately and thereafter annually on 1^st January until further notice,

and charge account number ________________ in the name of __________________________________

Signature _______________________________________ Date: _________________________________