MEMBERSHIP FORM 2015
1 FEES: All membership is due for renewal on the 1 st January each year. Payment can be made by cheque (Payable to: The Lusitano
Breed Society of Great Britain) or standing order (form below). If paying by standing order, please:

take part 6 of this form (overleaf) to your local branch (do not send to the Membership Secretary!) or

set up a standing order on-line
and fill in the reference details for the standing order below:
Date standing order to leave Member’s account
Amount of standing order payment
Member reference
We would greatly appreciate it if all European and Overseas subscriptions were paid by sterling draft or bacs payment. If this is not
convenient please contact the Membership Secretary to make other arrangements.
Please circle the Membership you wish to subscribe to:
Single Membership
£30.00
Family Membership
Junior Membership
£15.00 D.O.B (junior members only) . . . . . . . . . . . . . . Overseas/ EU Membership
(18 years and under as of 1 January of the subscription year)
2 MEMBERSHIP: Are you a new member?
renewing your subscription?
£50.00
£40.00
Membership No: ……………………………………
Please fill in the details below even if you are renewing your subscription as it helps us keep our records updated
Your Name: …………………………………………..………………… Name of account debited ………………………………..………….
NAME/s: Mr/Mrs/Miss/Title ………………………………………………………………………..………………………..…………….……….
ADDRESS:…………………………………………………………………………………………………………………………………………..
COUNTY: ………………..……..……. POSTCODE: ……………..…….…. TELEPHONE: ………………………………….………………
E-MAIL: ………………………………………………..…………………….………………….
3 HORSE OWNER: How many Lusitanos do you own?
Stallion/Colt
Mare/Filly
Gelding
Pure-bred
Part-bred
Other
4 How did you hear of the Society?
……………………………………………………………………………………………………………………………….
5 I confirm that I will abide by the rules which the Society may adopt for as long as I wish to remain a member
SIGN ………………………….…………………… PRINT NAME ………………………….……………… DATE …………………………….
If you do NOT wish your contact details to be published in the Society’s List of Members please tick here
We would like to save paper where possible by contacting you by e-mail rather than paper mail. Please tick here if you
consent to us doing so (you will still receive your hard copy Luso News)
Please complete this form sections 1 – 5 and return to the Membership Secretary:
Mrs Patricia Edgington, 4 Brassington Gardens, Withington, Gloucestershire GL54 4DG
e-mail patriciaedgington@hotmail.com
Company Limited by Guarantee No. 04830790 Registered in England & Wales
Registered Office : Bro Delyn, Unchmynydd, Gwynedd LL53 8BY
.
MEMBERSHIP FORM 2015
6 STANDING ORDER AUTHORITY – Please detach and forward to your bank for processing.
To: …………………………………………………………………………………………….……………………………………………………………… Bank
Address: ………………………………………………………………………………………………….…………………………………………………………..
…………………………………………………………………………………………………….……………………………………………………………
Town: …………………………………….……………. County: ……………………….……………………….. Postcode ……………………..…………….
Please Pay
Bank
Nat West
Branch Title
Machynlleth
The credit of
Beneficiary’s Name
The Lusitano Breed Society of Great Britain
The Sum of
Amount in Figures
£
Amount in words
Date of first payment
And thereafter – Due date and frequency
January 1st - Annually
Sort Code
53 – 81 - 26
Account Number
84507071
Continuing until you receive further notice from me/us in writing.
Quoting Ref: ……………………………………………………………………….. And debiting my/our account accordingly.
(Please ask your bank to quote your name as the reference.)
Please cancel any previous standing order or direct debit in favour of the beneficiary named under this reference.
Special instructions : ……………………………………………… ……………………………………………………………………………………………….
Account to be debited: …………………………………………………………………….. Account No: ……………………………………………………….
Signature (s): ………………………………………………………………………………. Date: ……………………………………………………………….
Company Limited by Guarantee No. 04830790 Registered in England & Wales
Registered Office : Bro Delyn, Unchmynydd, Gwynedd LL53 8BY
.