First name:

Last name:

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Country:

Telephone number:

Fax number:

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Type of Membership:

If applying for Corporate membership, state name of organisation and its main activity:

Please tell us a little about your interest in Historical Diving:

I wish to become a member of the Historical Diving Society. I enclose the appropriate fee and agree to abide by its Rules and Constitution.

Signed:

.........................................................

Date:

....................................................

For
Office
Use

Do you wish to pay by Standing Order? (UK Only)

YES/NO

The Society's Bank is:

National Westminster Bank, Merry Hill Centre,
Brierley Hill, West Midlands DY1 1LW, UK

Account Number 62713183
Sort Code 60-03-30

Payments should be in British Pounds (£ sterling), with cheques or drafts drawn on a UK bank

SECURITY CODE
last 3 digits of code on signature strip

EXPIRY DATE

NAME OF CARD HOLDER:

PLEASE POST COMPLETED FORM TO: Una Smillie, 29 Pingle Croft, Woodend, Chorley, Lancs, PR6 7UL, or FAX to 01772 493813