SOCIALIST HEALTH ASSOCIATION 22 Blair Road, Manchester M16 8NS 0161 286 1926
Membership fees are £25.00 a year or £10.00 reduced rate for people on low income
Your name and address:.............. .................................................... .................................................... ...................................................
Post Code.................................... Date of birth: ..............................
Name and address of your bank:...................................................... ................................................... .................................................... Post Code....................................
Your Account No.......................
Bank Sort Code .. .. .. .. .. ..
Please pay to the account of the Socialist Health Association, The Co-operative Bank plc, Heaton House, 151 Lewisham High Street, London SE13 6AA, Sort Code No. 08 90 29, Account No. 50457904.
on the ............... day of ......................... (month) 2011, the sum of £25.00, OR £10 and continue to pay this each year until further notice.
(Please delete as applicable)
Please cancel any previous standing order in favour of the Socialist Health Association
(SHA membership no. .. .. .. ..)(for office use)
Signed ........................................ Date ..................................
Please sign this and post it to us.