Membership Application Form (UK Only)

Type in your information, print the form and return to us at;
Mercedes-Benz Owners, Langton Road, Langton Green, Tunbridge Wells, Kent, TN3 0EG or fax to; 01892 861363
(If joining by standing order, please post form to us with original signature)

YOUR DETAILS

Name:

Address:


Town/City:

County/Province/State:

Post Code/Zip:

Day time Telephone:

Email Address:
YOUR VEHICLE DETAILS

Mercedes Model:

Year:

Owned Since:

Do you service your car yourself? YES NO

If no, please give the name and address of the garage:


Date Car Insurance expires:
Payment by Annual Standing Order - SAVE almost 20%
UK SILVER 3 OPTION ONLY
(Payment by Standing Order of UK Residents Only)

Your bank's name and address:


A/C Name:
A/C Number:

Sort Code:
 - -

Signature:


Date:
 - -

Please Pay:
NatWest Bank, Mount Pleasant, Tunbridge Wells, Kent TN1 1PX

For credit of Mercedes-Benz Owners A/C 01143719 (sort code 55-70-13) the following sums: £29 the last day of this month and then £29 ANNUALLY thereafter until cancelled by me in writing. This mandate cancels any previous order in favour of the beneficiary named above.

Payment by Credit Card or Cheque (please make cheques payable to Mercedes-Benz Owners)
Select as appropriate:


Silver Option (All the benefits and a monthly printed publication of Mercedes Owner magazine)

1 year I enclose a cheque for £35 Please charge my credit card for £35 (prices are for UK membership only)
2 year I enclose a cheque for £59 Please charge my credit card for £59 (prices are for UK membership only)

Blue Option (All the benefits and a monthly downloadable pdf publication of Mercedes Owner magazine)

1 year I enclose a cheque for £25 Please charge my credit card for £25 (prices are for UK membership only)
2 year I enclose a cheque for £45 Please charge my credit card for £45 (prices are for UK membership only)

Credit Card Number:

Issue Date:
- -
Expiry Date:
- - 		Signature:

Date:
  - -
Switch Issue Number:
Security Number last three digits on back of your card:

If paying by Standing Order or Credit Card please ensure that you have signed where applicable
© 2007 Mercedes-Benz Owners