Let the National Eczema Society help

(please print and complete this form)

PLEASE USE BLOCK CAPITALS 

Title: 		Mr [ ]		Mrs [ ]		Ms [ ]		other................

Surname					Forenames

Address



Post/Zip Code

Telephone

Date of Birth

Name of Person with eczema if different from above 

Date of Birth			Male [ ]	Female [ ]
Type of eczema (if known)


Where did you hear about the Society?

Please send me a (tick one only)

Baby & Child [ ]		Adult [ ]	Membership pack

I enclose my subscription of: 

		UK	[ ]	Overseas (non-UK) 	[ ]


		£20				£40

I would like to make a donation of £........................

Please make cheques payable to National Eczema Society

OR

Please debit my ACCESS/VISA/SWITCH card Account no _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Switch Issue No.:	_ _ _ _ _ _ _ _

Valid from:		_ _ _ _ _ _ _ _

Expiry date:		_ _ _ _ _ _ _ _

Signed...............................................................

GIFT AID:

[ ] (tick) I would like the National Eczema Society to reclaim tax on all
contributions I have made since 6th April 2000 and may make in the future*.

*You need to have paid an amount of income tax and/or capital gains tax
equal to the tax we claim on your gift (currently 28p in the £1). If
your tax situation or contact details change, please let us know.


DATA PROTECTION CLAUSE:

Personal information provided by you will be held on a database and may be
shared with subsidiaries of the National Eczema Society. This information
will be used to keep you informed of their products and services and for
fundraising. Sometimes your details may be made available to carefully
selected external organisations that wish to communicate with you. If
you do not wish your details to be used for any of these purposes please tick here [ ] 

Send your completed forms to: 

Membership Department, National Eczema Society, Hill House, Highgate Hill, 
London, N19 5NA. You can telephone the Society on 020 7281 3553 or Fax: 
020 7281 6395.

The National Eczema Society is a registered charity, No. 1009671 (England & Wales) and a company limited by guarantee reg. no. 2685083 (England & Wales).