Super 100 Heritage Club Application Form

The Dacorum Heritage Trust

The Museum Store, Clarence Road, Berkhamsted, Herts HP4 3YL.
Phone/fax: 01442 879525

Enter your details in the form below, then print it out and send it (with your remittance) to the address above.

Name: (Title/First/Last)
Email Address:
Telephone No:
Address:
Postal Code:
Please tell us which Societies you belong to: (if applicable)
How many tickets would you like to purchase? (£12 per ticket per year):
Total amount to pay:
Method of payment: (please tick method)	Cash Cheque Standing order (*See Note 1)
I would like all donations to be Gift Aided: (please tick)	Gift Aid (**See Note 2)
For office use only:	Date processed Renewal date Ticket number(s)
Note 1: If paying by standing order, please complete our Standing Order form and attach to this application form. Note 2: To qualify for Gift Aid, what you pay in income tax or capital gains tax must at least equal the amount that the charity will claim in the tax year. Signature: .................................................. Date: ...................