I wish to apply for Membership/Renew my Membership to the Leg Ulcer Forum.

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• I enclose a cheque for £15 made payable to the Leg Ulcer Forum

• I wish to pay by direct debit from my account

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(Paying via direct debit will ensure you don’t miss out on the benefits of membership, as your details will be kept on file until you notify us otherwise).

To set up a direct debit from your account, Leg Ulcer Forum Bank details are as follows:

Bank name: Barclays Bank

Branch: Staines - Sort Code: 20 81 11

Account Number: 10344443

Account name: The Leg Ulcer Forum

PLEASE USE CLEAR BLOCK CAPITALS

Name________________________________________________________________________

Prof/Dr/Mr/Mrs/Miss/Ms (Circle as applicable)

Job Title_____________________________________________________________________

Address______________________________________________________________________

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Post Code _________________________Telephone Number ________________________

Email  __________________________________________

Please return to:- The Administrator, Leg Ulcer Forum,

PO Box 337, Huntingdon, PE28 2WH