Membership Application

Name(s)    
 
Address    
 
     
 
     
 
     
 
Postcode    
 
Telephone Number    
 
Email Address    
 
Type of Membership    
 
Amount Enclosed    
£ 
Date    
 

Subscriptions rates are as follows:

Individual £10
Family (2 or more at the same address)   £15
Concession (unwaged or OAP) £5
Group with similar objectives £15
Corporate £50

Subscriptions are effective from 1st January to 31st December. Members enrolling after 1st July pay half subscription. Please make cheques payable to 'Potteries Heritage Society'.

Please send this form with your subscription to:

The Treasurer
Potteries Heritage Society
Burslem School of Art
Queen Street
Burslem
Stoke-on-Trent
ST6 3EJ