BURY AND BOLTON ME/CFS & FIBROMYALGIA SUPPORT GROUP Membership Application/ Renewal Form

Registered Charity: 1161356

The Bury and Bolton ME/CFS & Fibromyalgia Support Group membership fee is a minimum annual donation of £10 please. Membership runs from 1st April – 31st March each year. Your donation is important, as it not only helps to run the group, it funds our campaign for awareness and NHS medical provision.

We are working with The Fibromyalgia Association UK (FMA UK).

I am a new member I am renewing an existing/lapsed membership

Mr/Mrs/Miss/Ms/Other …………….......... Surname …………………………………………….

First Names ………………………………………………………………………...........................

Address ……………………………………………………………………………………………….

…………………………………………………………………… Post Code ………………………

Telephone Number(s):

Landline (including area code): ..................................... Mobile: ............................................

Email Address …………………………………………………..................................................

Date of Birth ……………….....................

------------------------------------------------------------------------------------------------------------------------------

Do you have ME/CFS? ………………....... Duration (months/years) ……………………….....

Do you have Fibromyalgia? ……………… Duration (months/years) ……………………….....

Do you have Long Covid? ........................ Duration (months/years) .....................................

Have you had a positive diagnosis? YES/NO. (You do not need a diagnosis to join our group).

If YES please give details of who diagnosed you? e.g.Self/GP/Hospital/Other: ………………………................................................................................................................

How did you hear about the Group? ………………………………………….............................

I would like to receive newsletters via: ◻ Email (saves us funds) ◻ Post

I enclose the sum of £ ……as a donation towards the work of the Bury and Bolton ME/CFS & Fibromyalgia Support Group, those affected by the conditions, and their carers.

I will be paying for my membership by:

Online Bank Transfer	Standing Order	Cheque

Please email the completed form to bbmemembership@outlook.com or post to BBME Group,

2 Lund Avenue, Radcliffe, M26 1BS.

Annual Membership Fee Payment

Payment methods available are as follows:

Online Bank Transfer details:

Sort Code: 20-10-71

Account No: 00902179

Account Name: Bury and Bolton ME/CFS & Fibromyalgia Support Group.

Standing Order:

Please complete the Standing Order Form below and send it to your bank, not us. Once set up only you can cancel your Standing Order, not us.

Cheque:

£10 payable to “Bury and Bolton ME/CFS & Fibromyalgia Support Group” please. You can bring it to a meeting, or send to:

BBME Group, 2 Lund Avenue, Radcliffe, M26 1BS.

Whichever payment method you choose, please put your name as the Payment Reference so we can identify your payment.

•

Please consider setting up an annual Standing Order or annual bank payment, for automatic payment in April. This saves us lots of admin, and saves you hassle too!

While online bank transfer and standing order are easiest for us to administer, please let us know if you are having any problems, we’re here to help. Many thanks for your continued support.

Standing Order Form

Registered Charity 1161356

1. Details of the account where payments will come from:
Name on Account:
Sort Code:
Account Number:
Name of Bank or Building Society:
2. Details of the account where payments will be sent to:
Account Name:	Bury and Bolton ME/CFS & Fibromyalgia Support Group
Name of Bank:	Barclays Bank
Sort Code:	20-10-71
Account Number:	00902179
Branch Address:	1-5 Market Street, Bolton, BL1 1BU
Payment Reference:
3. Payment details
Regular Amount (in figures):	£
Frequency:	Yearly

I hereby instruct my bank to make the above payment to Bury and Bolton ME/CFS & Fibromyalgia Support Group every year, and continue payments until cancelled by me/us in writing.

Signature:
Signature (if joint account):
Date:

ONCE COMPLETED, PLEASE SEND THIS PAGE TO YOUR BANK