The NOA 200 Club

Application Form for Gift Membership – please complete separate forms if you

wish to give membership to more than one recipient.

Please note that both purchaser and recipient must be at least 16 years of age.

Your details:

Name: ………………………………………………………………….

Address: …………………………………………………………………..

…………………………….....… Postcode:…………………..

Telephone Number: ………………………………………………………………….

E-mail Address: …………………………………………………………………..

Details of recipient:

Name: ………………………………………………………………….

Address: …………………………………………………………………..

…………………………….....… Postcode:…………………..

E-mail Address: …………………………………………………………………..

Details of gift certificate required:

Design (see advert): Christmas □ or General □

Format: Certificates will normally be sent as a PDF e-mailed to you.

If you need a paper certificate, please indicate whether it should be

posted to you □ or posted direct to the recipient □

How many shares (£24 per share, for entry into the next 4 prize draws) would you

like to give to this recipient? …………….

Payment (Please complete as appropriate)

I enclose a cheque for £ …….., payable to ‘NOA 200 Club’ □

or:

I have transferred the sum of £ …….., direct to the NOA 200 Club

bank account, number: 70589993, sort code: 20-46-65 □

quoting the surname and postcode of the recipient

Please return this form to:

Ann Newman, 6 Nelson Drive, Hunstanton, PE36 5DU, or by e-mail to ann.noa200@gmail.com

Deadlines for Christmas 2011

Your form must arrive

by Monday 12 December for postal despatch (2^nd class) by Saturday 17 December

by Monday 19 December for e-mail despatch by Saturday 24 December

Full details of the NOA 200 Club, including Club rules, can be found here

Please note that Gift membership of the Club is not currently available by standing order.