Royal College of Science Association Membership Form

Type: Change of Membership Details

Please remember to always quote your membership reference number, your first names and your surname to help us in making these changes. Please fill in ONLY the parts of the rest of the form that you would like us to amend on your membership file and sign and date the bottom of it. If your surname has changed, please indicate this by quoting both names and marking your new surname by circling it.

Membership Code:_________________
Title (Prof, Dr, Mr, Miss, etc): _________
First names:_________________________	Surname:_______________________

Email:_____________________________

Home Telephone:__________________

Work Telephone:___________________

Correspondence Address:	________________________________________
	________________________________________
	________________________________________
Post Code:	_____________________________

Membership Category Change*:

Please change my membership category to the one indicated below#:

____	Annual	£10	[Per Annum]
____	Installment Life	£25	[Per Annum for 10 Years]
____	One-Payment Life	£200	[Single Payment]

I agree to complete and return a Standing Order mandate in favour of the RCS Association, save if I undertake the ‘One-Payment Life’ membership scheme.

Signed: _________________________	Date: ________________
* tick one

# If applying for One-Payment Life Membership, please send cheque for Life Membership with this form to the Office made payable to 'RCS Association'. Standing Order forms will be sent to those applying for Installment Life Membership or Annual Membership on receipt of this form.

Please print out this form and complete and return it to the Royal College of Science Association, c/o Office of Alumni and Development, Imperial College London, Level 2, Faculty Building, London SW7 2AZ