Membership Form - 2015 - Join or Renew

Join or Renew
Thank you for deciding to join the Liberal Democrats or renew your membership. The minimum membership subscription fee
is £12. Concessionary subscriptions of £6 are available to students, those under 26, and anyone who is entitled to receive
state benefits (other than the state pension or child benefit). The recommended membership subscription fee as agreed by
members at the Party’s Federal Conference is £70.
1) About You
I will make an annual contribution of: £
First Name:
Please select ONE of the options below By Direct Debit (split into monthly payments):
By Direct Debit (split into quarterly payments):
By Direct Debit (as a single annual payment):
By Cash or Cheque (made payable to the
Liberal Democrats:
By Credit or Debit Card (complete details over
the page):
Date of Birth:
2) Your Payment Details
Please complete this section for Direct Debits. For card, cash or cheque payments please fill in the details over the
Instruction to your Bank or Building Society to pay by Direct Debit
Name and address of your Bank or Building Society branch
To: The Manager:
Originator’s Identification Number: 9 1 4 0 0 6
Name(s) of account holder(s):
Sort Code
Bank/Building Society
Account No.
Liberal Democrats’ Reference Number
Banks and Building Societies may not accept Direct Debits for
some types of account.
5. Instruction to your Bank or Building Society
Please pay the Liberal Democrats 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 Liberal Democrats and, if so,
details will be passed electronically to my Bank/Building Society.
3) Returning this form to us
Please return this form to Liberal Democrats (Membership Department), FREEPOST RSTK-HKSH-EJGE, 8-10
Great George Street, London, SW1P 3AE
The Direct Debit Guarantee
This guarantee is offered by all Banks and Building Societies that accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit, the
Liberal Democrats will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request the Liberal Democrats to collect a payment, confirmation
of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit, by the Liberal Democrats or your Bank or Building Society you
are entitled to a full and immediate refund of the amount paid from your bank or building society if you receive a refund you are not entitled to, you must pay it back when the Liberal
Democrats asks you to You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.
Pay by credit or debit card
Card Number
Start Date
Cardholder Name and Address:
Expiry Date
Issue Number
Security Code
Pay by cash or cheque
Please make cheque payable to “Liberal Democrats”. If sending cash, please use a secure method of posting, such
as special delivery.