MEMBERSHIP APPLICATION FORM
Please print this form, fill in the section below and post with your payment to:-
Mr John Beresford
Membership Secretary
The Beresford Family Society
37 Station Road
Barrow Hill,
Chesterfield
Derbyshire
S43 2NL
United Kingdom.

NAME & ADDRESS
Mr/Mrs/Miss/Ms...........Firstrname/s................................Surname....................................................
Firstname/s of Spouse.............................................................
Address..................................................................................
..............................................................................................
..............................................................................................
Town..........................................County..................................Country....................................
Postcode....................Tel No.................................Fax No.................................
E-mail Address...................................................................................

I wish to become a member of the BERESFORD FAMILY SOCIETY and enclose a
Cheque/Postal.Order to the value of £................ made payable to The Beresford Family Society and endorsed
A/C PAYEE.

Overseas members are asked to pay using Sterling Cheques where possible in order that
the Society may avoid currency conversion charges.

UK Subscription £15.00 UK Pounds p.a. OVERSEAS Subscription £15.00 UK Pounds p.a.

SIGNATURE..............................................................................................DATE..........................

If your occupation or hobby enables you to give particular help to the Society please give details below

....................................................................................................................................................

NOTE:Please list overleaf details of Beresford Parents, Grandparents and any other known ancestors.