200 Club Membership Application Form

200 Club Membership Application Form PLEASE COMPLETE THE FORM IN BLOCK CAPITALS Name: Address:

Contact Telephone Number: Email Address: (Required to keep you informed of how much money has been raised and how your money is being used)

I agree to abide by the rules of the Verulam School 200 Club Signed:___________________________________________________ Date:_________________ (Please make cheques payable to Verulam School PTA 100 Club)

Contribution please tick as appropriate: Monthly Contribution £5  £10  £15  Other __________ (multiples of £5 please) One-off payment (minimum of £10) _______________ (cheques payable to Verulam School PTA 100 Club)

STANDING ORDER To the Manager: Bank: Branch: Address:

Please pay to Barclays Bank PLC, St Albans Branch, PO Box 104, St Albans, AL1 3AN. Sort code: 2074-09, for credit of Verulam School PTA 100 club, account number 80922501 The monthly sum of £___________( _______________pounds) on the ________________ day of _______________20____ and thereafter on the 1st of the month. Account Name: Account Number: Sort code: Reference for Bank: (to be completed by PTA) Signed:___________________________________________________ Date:_________________

Please return completed form either direct to: Jeff Seymour, 25 Kingsbury Avenue, St Albans, AL3 4TA or email [email protected] (Telephone: 07786 393088) or to: Verulam School Reception clearly marking envelope “PTA 200 Club”