Pacific Islands Society
of the United Kingdom and Ireland

Membership Application

I/We wish to join the Pacific Islands Society of the United Kingdom and Ireland as:

an individual                    [   ]                                  a family            [   ]

a UK student                   [   ]                                  a serving VSO   [   ]

a Pacific Islands Student   [   ]

Mr/Mrs/Ms/ Other title____

Name(s) (BLOCK CAPITALS)______________________________

Address _________________________________________________

________________________________________________________

_________________________________ Postcode_______________

Telephone ________________________________

E-mail____________________________________

Pacific connection/country ____________________________________

________________________________________________________

I enclose a Cheque/Postal Order/Money Order for:

Subscription £ _______

Donation      £ _______

Total            £ _______
 

I request a standing order mandate form  [   ]

Signed____________________________                                            Date____________________

 Please send to the Membership Secretary:

   Mr. David Evans,  9 Pershore Road, Halesowen, West Midlands, B63 4QJ, United Kingdom