--------------------------------------------------------------
UKAMB Membership Form

Institution or Support Group..................................

					Tel...................

Contact name or individual....................................

					Tel...................


Address:......................................................

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

Post Code:....................Email...........................

Annual subscriptions (please tick)

Milk Bank (voting) 	£100__	Supporting group	£50__
Individual (voting)	£25__	Individual (non voting) £15__
Corporate (non voting)	£500__

I enclose a cheque for ......

Please make cheques payable to UKAMB and return form to:

The Milk Bank
Queen Charlotte's and Chelsea Hospital
Du Cane Rd
Hammersmith
London
W12 0HS
--------------------------------------------------------------