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Do you wish to apply for two memberships at the same address?
NoYes

Name *
Title —Please choose an option—MrMrsMissMsDrProfRev
First name
Last name

Address *
Address 1
Address 2
Town
Postcode

Email *

Phone *

Mobile phone

Emergency contact name and number

How did you hear about us?
WebsiteNewspaperLibraryFriendOther

Groups or activities you are interested in (including any ideas for new ones)

[group two-members]

Second applicant

Second applicant's name
Title —Please choose an option—MrMrsMissMsDrProfRev
First name
Last name

Email (if different from above)

Phone (if different from above)

Mobile phone

Emergency contact name and number

Groups or activities you are interested in (including any ideas for new ones)

[/group]

Name of charity: Dorking & District u3a
Charity number: 1005743

Gift Aid helps us to keep subscription rates at an affordable level at no extra cost to you. If you would like your membership subscription to be treated as a Gift Aid donation, please read the declaration below and ensure that Yes is selected.

I am a UK taxpayer and I would like Dorking & District u3a to treat my membership subscriptions paid from today, until notified otherwise, as Gift Aid donations. I confirm that the amount of Income Tax and/or Capital Gains Tax that I pay each year is greater than any tax reclaimed.

Gift Aid
YesNo

• Please notify Dorking & District u3a if you want to cancel this declaration, if you change your name or home address, or if you no longer pay sufficient tax on your income and/or capital gains.

Privacy statement

Dorking & District u3a requires members to provide their personal information so that you can be kept informed about events and activities that are offered as part of your membership. In collecting your information Dorking & District u3a will:

• Store it securely;

• Use it to communicate with you as a u3a member;

• Share it with group leaders for those interest groups that you are a member of; and

• Send you general information about the Third Age Trust (the national organisation to which u3as are affiliated).

Magazines direct mail

Are you happy to be added to the direct mailing list for Third Age Trust magazines Third Age Matters and Sources? If so, please opt in below.

Magazine mailings
YesNo

• You can request that your data not be used for any of these purposes at any time by contacting the Membership Secretary.