Lloyd's Flyfishing Society

Application for membership.

Please answer the following questions and complete the Standing Order Mandate form below. Please detach and send the Standing Order Mandate Form to your Bank and return the top section of the form to the Secretary, Brian Fitzsimmons, "Windmolen", White Horse Road, East Bergholt, Suffolk, CO7 6TU.

Full Name: ............................................................................................................................Home Tel. .....................................

Home address: ..............................................................................................................................................................................

                  ............................................................................................................................Post Code .........................................

Business Address: .......................................................................................................................................................................

                  ..................................................................................................................................Post Code ....................................

Business telephone: ...............................................................................................Mobile:........................................................

Email address: ...............................................................Lloyd's Membership No. .................................................................

Introduced by Existing Member: .........................................................Date: .........................................................................

Detach and send to your Bank ----->---->---->---->---->---->---->.--->---->---->---->---->---->---->---->---->---->---->---->----

BANK STANDING ORDER MANDATE

PLEASE PAY TO  : NATIONAL WESTMINSTER BANK PLC. Sort Code: 56-00-18.

                                116, Fenchurch Street, London, EC3M 5AN

For the credit of "LLOYD'S FLYFISHING SOCIETY ", Account No. 08107335, the sum of £35.00 (thirty-five Pounds Sterling), being the first year's subscription, immediately, and thereafter, the sum of £15.00 annually on the 1st January until you receive further notice from me in writing.

Account Name (in Caps)......................................A/c No:.......................Sort Code:...................

Bank:......................................................................Branch:..........................................................

Address....................................................................................................Post code:....................

Signature:......................................................................