MEMBERSHIP NO.
Fill in form using BLOCK CAPITALS
NAME ADDRESS POSTCODE MOBILE NO.
PHONE NO. E-MAIL DATE OF BIRTH GENDER: M/F RETIRED:Y/N (please ring as appropriate) TRADE UNION OCCUPATION PLACE OF WORK/STUDY SKILLS/QUALIFICATIONS (i.e. Other Language(s), Design, Legal, Research, Childcare etc.) TU/PROG. MOV. POSITIONS MEMBERSHIP OF: PPPS [ ] MML [ ] PSC [ ] OTHER ORGANISATIONS CO-OP [ ] CND [ ] YCL [ ] CSC [ ] BRANCH DISTRICT/NATION Dues rate per month
£12 waged £6 reduced waged £2 unwaged £1 reduced unwaged
I would also like to make an additional monthly (please specify) contribution to quota of £ (Your Direct Debit will be claimed on the third of each month, or the next working day)
Monthly total deducted from my account £ Communist Party of Britain Please Fill in whole form and return to CPB, Ruskin House, 23 Coombe Rd Croydon CR0 1BD
INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY BY DIRECT DEBIT
Name & full address (inc. postcode) of your bank/Building Society To: The Manager
Bank/Building Society
Originator’s Identification Number
9 7
Address
4
2
5
0
Reference Number (For CPB Office to fill in)
Postcode
Name of Account Holder(s)
Instruction to your Bank or Building Society Please pay Communist Party of Britain Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct Debit guarantee. I understand that this Instruction may remain with the Communist Party of Britain and, if so, details will be passed electronically to my Bank/Building Society Signature(s)
Branch Sort Code
Bank/Building Society Account Number Date
Banks & Building Societies may not accept Direct Debit Instructions for some types of account