MEMBERSHIP AND RENEWWAL FORM

CUBA SOLIDARITY CAMPAIGN
MEMBERSHIP AND RENEWALS FORM

(Print this page and send it to the address provided)

For CSC Office Use

Payment Received and Processed

New Members Pack Sent

Database Updated

Please complete all the details below so we can check our records and return to:

CSC, Red Rose Club, 129 Seven Sisters Road, London N7 7QG.

New member or Renewal: NEW / RENEWAL

Name: _________________________________________________________________

Address: _________________________________________________________________

___________________________________________________________________________

Home Telephone : ___________________________________________________________

Work Telephone : ___________________________________________________________

Trade Union : ___________________________________________________________

Email Address : ___________________________________________________________

Are you a student? YES / NO College : ______________________________________

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How would you like to pay? Please tick just one of the lines below.

____ I am waged and have enclosed a cheque / PO for £15

____ I am unwaged and have enclosed a cheque / PO for £5

____ I would like to pay by standing order and have completed the form below

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Standing order form (Please return to CSC - not your Bank)

Your Name : _________________________________________________________________

Address : _________________________________________________________________

Account Number : ______________________________________________________

At (Name & address of bank) : _________________________________________________

___________________________________________________________________________

Pay Cuba Solidarity Campaign, Co-operative Bank, 1 Islington High Street, London N1 9TR,

Sort code 08 90 33 Account Number 50425169

£___________every month / year starting on (date)______________until further notice.

Signature _________________________________________________________________