Membership Form

Also available as a PDF or Word document

Contact Details

Please write legibly. All details will remain confidential.

Title:	Initials:
Surname:
Address:

Tel:	Fax:
E-mail Address (required):

Current Fees

Please circle one box:

Type of membership	Fee
Full Membership	£ 30
Retired / Career Break / Unemployed	£ 15
Student Membership	£ 15

Payment

It is possible to pay by cheque, credit/debit card, internet transfer or by standing order; the MGMS would like to encourage you to set up a standing order payment as this is the preferred method.

By Card:
Please circle card type: Switch / Delta / Visa / Mastercard
Sorry, we do not accept American Express.

**Payment Methods**

Tick box that applies:
By Standing Order / Internet Banking The Membership Secretary will email you with the MGMS bank account details on receipt of your completed form.
By Cheque Please make cheques payable to *Molecular Graphics & Modelling Society*

**Card Details**

**(Please send card details by recorded delivery or courier. DO NOT send card details by normal mail, email, or fax)**
Card Number: (16 digits for Visa/Delta/Mastercard, 18 for Switch)
Security Code: (Last 3 digits on signature bar)	Expiry Date:	Issue Number: (Switch only)
Card billing address:
If receipt required, tick box: Please return by email [__] or post [__] (enclose a stamped, addressed envelope).

Signatures

Signature:

Date:

For student membership, a supervisor’s signature is also required:

I hereby declare that the above is a student.

Supervisor’s
Name: