By completing this form, including the Standing Order Mandate, I hereby apply to subscribe to the services provided by grape-juice, as described in this application form and related documentation (comprising the web site, www.grape-juice.com, the documents attached thereto and contained therein) for a minimum period of one year.

I agree to be bound to the terms and conditions, as may be varied at any time by grape-juice and published on www.grape-juice.com.

I wish to pay a monthly amount of £_______ (must be a whole multiple of £120).

Enclosed is a cheque (payable to grape-juice limited) for £_______ (comprising my initial fee of £_______ and my first monthly payment of £_______ for the month of _______________). [The first monthly payment included with this cheque will be for the month of joining and standing orders will be due on the first day of the following month. See the costs page of our website or contact us at info@grape-juice.com or at the above address for more information.]

In relation to the referral offer, the member who introduced me to grape-juice, and to whom any applicable referral payment should be made, was _____________________.* [OR] I heard about grape-juice through _____________________.*

Yours faithfully

Signature:

Name:

Date:

Postal address:

E-mail address:

Contact phone number:

Should you wish anyone else to receive our member updates please give their email address:


Please complete all details in full.
* Delete as applicable

STANDING ORDER MANDATE

This standing order mandate should be completed in full and sent to grape-juice (who will send it to your bank) along with the application form.

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From: [your name and address]

To: [your bank's address]
The Manager

Account details: [your account details]
Account holder:

Account number: _ _ _ _ _ _ _ _

Sort code: _ _ / _ _ / _ _

Please set up a new monthly standing order from the above account to pay:
Abbey National PLC Business Banking
PO Box 126
Newport, NP19 7BF

Account details:
grape-juice limited client a/c
Account number: 40309518
Sort code: 09 / 06 / 66

The monthly amount of: [£120 or a multiple thereof]

£_______

Ref [initial & surname] _______________

The first payment relating to the above instruction is to be made on the first day of ____________ [month**] continuing on the first day of each month until further notice. This order cancels all previous standing orders in favour of grape-juice limited.

Name:

Signature:

Date:

** The first monthly payment is included in the initial cheque sent with this application form. The standing order should commence from the first day of the second month of membership.