Membership Application Form

If you would like to become a member of the Myotonic Dystrophy Support Group please complete this form and return it with a cheque for £10 made payable to the Myotonic Dystrophy Support Group to: Myotonic Dystrophy Support Group, 35a Carlton Hill, Carlton, Nottingham, NG4 1BG. For overseas membership please contact the group for further details. The Myotonic Dystrophy Support Group is a registered charity no. 1073211.

I/We wish to apply for membership of the Myotonic Dystrophy Support Group

Title___________First name ____________________ Surname_____________________

Address _________________________________________________________________

_________________________________________________________________________

Post code__________________

Telephone no. (including area code) ____________________________________________

Email address ______________________________ Number of family members_______

£10 per member (membership covers all family members within a household)

Please indicate Method of payment -

Cheque - made payable to Myotonic Dystrophy Support Group _________

Postal order - made payable to Myotonic Dystrophy Support Group ________

Direct Debit - please return details with this form to the above address ________

If you would like to make an additional donation with your subscription please indicate below

£5 ________ £10_________ £20 _________ Other________________

If you pay tax, the Myotonic Dystrophy Support Group is able to reclaim the tax already paid on your donation, as long as you have paid or pay an amount of income tax / capital gains tax equal to or greater than that reclaimed on donations. If this applies to you please fill in the gift aid declaration below.
Gift Aid Declaration
I want the charity to treat the enclosed amount of £................. as a gift aided donation and all donations I make from the date of this declaration until I notify you otherwise.

Date ........./........./........... Signed .......................................

Thank you for supporting our work