File number (colleague / personnel no.) *

Title	Forename(s) *	Surname *
Mr Mrs Miss Ms Master Dr Rev Sir

Contact Details

Work details

Ethnic Origin (please tick where applicable)

White		Bangladeshi		Black-American		Black Other
Other		Chinese		Indian		Asian other
Pakistani		Black-Caribbean		Not Specified

Date of Birth

DDMMYY

Who recommended you to join Accord?

Name	Accord Membership no. or File number (colleague / personnel no.)

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I hereby authorise payment to the account of Accord by monthly DD to the amount of:

(Downloadable DD form available after submission)

Full time £8.80		Part time (less than 16hrs) £3.80
Short term (full time) £5.80		Under 21 years old £3.80
Part time (16 or more hours) £5.80

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Every month, Accord’s subscription draw gives away £12,500 in cash. You can buy up to five tickets every month, costing just £1 each. The top prize is £5,000, there are 10 runner-up prizes of £500 and 25 members win £100.

I wish to purchase the following number of tickets for each month’s draw at a cost of £1 each* (click on the number of tickets you require).

If you do not wish to buy any tickets, tick "No tickets, thank you".

1 ticket
2 tickets
3 tickets
4 tickets
5 tickets
No tickets, thank you.

I have read and agree to be bound by the rules of the Accord Subscription Draw, available at www.accord-myunion.org

* The amount is added to your monthly membership payment

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Terms and Conditions

Deductions to commence on the date following receipt of authority. This authority to continue until cancelled by me in writing. I also agree to my monthly subscription being increased to the appropriate rate if the subscriptions of Accord are increased in accordance with the Rules. I further agree that Accord may process my personal data in accordance with their Fair Processing Notice.

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* I have read and agree to the terms and conditions above.

In the next stage, you will be prompted to download a Direct Debit form. On receipt of this printed and filled in form, we will process your application.