Haiti Support Group affiliation form

AFFILIATION FORM

WHAT YOU CAN DO:

HELP THE HAITI SUPPORT GROUP TO CONTINUE ITS WORK

AFFILIATE NOW

YOU WILL RECEIVE FOUR ISSUES OF THE 'HAITI BRIEFING ' NEWSLETTER,
ALL THE UP TO DATE NEWS FROM HAITI AND ABOUT EVENTS AND CAMPAIGNS BY EMAIL.

Print out and fill in this form (below), and send with payment details by mail to

The Haiti Support Group at:
10 Swingfield House,
Templecombe Road
London
E9 7LX
United Kingdom

AFFILIATION to THE HAITI SUPPORT GROUP
Annual rates

ALL TRANSACTIONS MUST BE IN STERLING CHEQUE OR CREDIT CARD(*see bottom of page)
Individuals : Ł25/10 for unwaged)

Organisations : Ł75

Supporting affiliation : Ł150

I enclose a cheque for Ł..........
Name.......................................................................
Address...................................................................
.................................................................................
.................................................................................
.................................................................................
Email address................................................................
Please debit my credit card
Card type : Visa/Access/Mastercard
Card No......................................................................
Expiry date.................................................................
Amount Ł..........................

Signature....................................................................

*CREDIT CARD TRANSACTIONS WILL BE HANDLED BY THE
CATHOLIC INSTITUTE FOR INTERNATIONAL RELATIONS (CIIR)

Thank you for your interest in The HAITI SUPPORT GROUP.