Executive Member£5,000.00Executive Member RegistrationTitleSelect OptionMr.Mrs.MissMsSirDr. Title * First Name * Last Name Spouse Name * Email Address * Phone No. Address CityCountySelect OptionBedfordshireBerkshireBristolBuckinghamshireCambridgeshireCheshireCity of LondonCornwallCumbriaDerbyshireDevonDorsetDurhamEast Riding of YorkshireEast SussexEssexGloucestershireGreater LondonGreater ManchesterHampshireHerefordshireHertfordshireIsle of WightKentLancashireLeicestershire LincolnshireMerseysideNorfolkNorth YorkshireNorthamptonshireNorthumberlandNottinghamshireOxfordshireRutlandShropshireSomersetSouth YorkshireStaffordshireSuffolkSurreySussexTyne & WearWarwickshireWest MidlandsWest SussexWest YorkshireWiltshireWorcestershireNorthern IrelandScotlandWales County Country Post Code/Zip* I want to Gift Aid this donation (Please enter your address if you want to declare GiftAid)YesNo* I would like to be part of the volunteering team. Please contact me.YesNo* I am happy for my name to be published in SJS UK Website as part of the member listYesNo* I hereby agree to abide by the rules and regulations as published in the constitution of SJS UK. I give SJS UK my consent to be contacted so that I can be kept informed about the Jagannatha temple project progress and other communications via email, phone, or any social media channel.*AgreeDone(Use Cropper to set image and use mouse scroller for zoom image.) Use Barclays bank details for the payment (See below)Bank TransferReference ID / SJSUK_(Your First Name)_(Your Membership Type)Reference ID / SJSUK_(Your First Name)_(Your Membership Type)Please enter Reference ID / SJSUK_(Your First Name)_(Your Membership Type).Bank NameBank NamePlease enter Bank Name.Account Holder NameAccount Holder NamePlease enter Account Holder Name.Additional Info/NoteAdditional Info/NotePlease enter Additional Info/Note.How you want to pay?Auto Debit PaymentManual PaymentPayment SummaryYour currently selected plan : , Plan Amount : Submit
