Membership Application Form

(please print this form and post it along with your membership fee to the address on the previous page)

*items must be entered

Type of Membership:*		Duration (1/5 years):*
Title:*
Forename:*
Surname:*
Name of Organisation / Business:		Size of business:
Address:*
Postcode:
Telephone Number:		Fax Number:
Email:*

CRB Checking service required?

Yes

Number of CRB Froms Required

We/I wish to apply for membership of BRCC and enclose a fee of �

We/I would like to pay renewal fees by standing order		Yes		No
I would like to increase the value of my subscription by completing a Gift Aid declaration		Yes		No

Signed

Date

Data Protection

BRCC holds the information provided by you for the purpose of membership administration and the provision of membership services, including CRB checking and the Community Transport Brokerage. The information is held within BRCC�s central computerised database and members, clients and beneficiaries. The information will not be provided to third parties except where applicable to other members of the Community Transport Brokerage. In addition to mailings directly related to your membership of BRCC, and to the CRB service and Community Transport Brokerage where relevant, we would also like to send you information about BRCC activities, projects and services. If you would not like to receive these mailings please tick this box.

Would you like to receive these mailings?

Yes

Conditions

Should the Charity be wound up, every member undertakes to contribute up to �10 to the Charity's assets for payment of the Charity's debts and liabilities, as stated in pragraph 7 of BRCC's Memorandum of Association.

[return to members page]

Office Use Only

Database Updated	Email Sent	Certificate Sent	CRB Pack Sent	T & Cs Received