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Southwark Civic Association APPLICATION FOR FULL MEMBERSHIP Please complete this form and return it to: The Honorary Secretary, Southwark Civic Association, C/o: The

Civic Suite, Third Floor, 160 Tooley Street, London SE1 2Q H

Section A:

MEMBERSHIP CATEGORY (Please tick box):

□ Individual member: £15 (Please complete Section B)

□ Corporate member (20+ Employees): £250 (Please complete Section C)

□ Local Organisation/ Society: £30 (Please complete Section C)

□ Small Business (Up to 19 Employees): £100 (Please complete Section C)

Section B:

INDIVIDUAL DETAILS

Title Surname Forenames Address Line 1 Address Line 2 Address Line 3 Address Line 4 Post Code Telephone Number E-mail Address Occupation Section C:

CORPORATE/ BUSINESS/ ORGANISATION DETAILS

Company/ Organisation Name Address Line 1 Address Line 2 Address Line 3 Address Line 4 Post Code Telephone Number E-mail Address Web Site Title of Representative to SCA Forename of Rep. to SCA Surname of Rep. to SCA SCA – APPLICATION FORM. VER.2


Section D:

FURTHER DETAILS

1. How did you hear about the Southwark Civic Association (SCA)? (Please tick box): □ SCA Member

□ SCA Literature

□ SCA Promotional Event

□ SCA Civic Awards

□ Southwark Council Literature □ Local Press □ Friend/ Colleague/ Family Member Other (Please give details): ______________________________________________________________ ______________________________________________________________ 2. Are there any activities or events that you would particularly like the SCA to run or become involved in? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 3. The SCA is run and administered by its members. Are you/ your organisation able to offer any support or resources to the SCA (e.g. Sponsorship, help with publicity/ marketing, helping at events, etc.)? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 4. Signature of Applicant: _______________________________________ Date:________________________________________ Thank you for your interest in joining the Southwark Civic Association. We will contact you about your application shortly. Data Protection: The information you provide will be used fairly and lawfully and Southwark Civic Association will not knowingly do anything which may lead to a breach of the Data Protection Act 1998.

SCA – APPLICATION FORM. VER.2

Southwark Civic Association Full Membership Application Form  

Southwark Civic Association

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