A. To be completed by a candidate (wypełnia kandydat)

THE ASSOCIATION OF POLISH ENGINEERS IN GREAT BRITAIN LTD
STOWARZYSZENIE TECHNIKÓW POLSKICH W WIELKIEJ BRYTANII
Established in 1940
Założone w 1940r
Address: 238-246 King Street, London W6 0RF, United Kingdom.
Tel: +44(0)20-8741 1940; Fax: +44(0)20-8746-3798; Web: www.stpuk.org, e-mail: [email protected]
APPLICATION FORM – Supporting Member
Wypełniony formularz należy wysłać na adres: PCU UK, Suite 19, Central Chambers, Ealing, London W5 2NR
lub zeskanowany na adres e-mail: [email protected]
A. To be completed by a candidate (wypełnia kandydat):
Applying to become Supporting Member of the Association of Polish Engineers in Great Britain Ltd, which
enables to become a member of the Polish Credit Union UK, on the basis of the Common Bond.
Aplikacja na członka wspierającego Stowarzyszenia Techników Polskich w UK tworzącego Common Bond
Polskiej Unii Kredytowej w UK.
1. Surname and forename:
/Nazwisko i imię/
....................................................................................................................................................................................
2. Home address and contacts:
Residence address in the UK: .....................................................................................................................................
/Adres w UK i kontakty/
Tel:...............................................E-mail..............................................................Web...............................................
3. Contacts at Work:
Name of the Company and its address:
/Nazwa firmy i adres oraz kontaktowe adresy/
......................................................................................................................................................................................
Tel: .............................................E-mail..............................................................Web................................................ 4. Position/function. Since when?
/Stanowisko/funkcja i od kiedy/
....................................................................................................................................................................................
5. Date and place of birth: .......................................................................................................................................
/Data i miejsce urodzenia /
6. Status in the United Kingdom- since when?: ......................................................................................................
/Status pobytu w UK i od kiedy/
I declare the information given by me is correct.
After confirmation of my Supporting Membership I undertake to pay the membership fee of £5.00 per annum from
my PCU UK deposit account for the benefit of APE. In case of any change to the APE membership fees I need to
agree to such changes and sign a new agreement.
Deklaruję, że podane przeze mnie informacje są prawdziwe. Po uzyskaniu członkowstwa będę płacił £5.00
corocznej składki , która będzie potrącana z mojego konta depozytowego w PCU UK na rzecz STP. W razie
zmiany opłat członkowskich wymagana jest moja zgoda na jej wysokość i sposób płacenia.
Name of an applicant /Nazwisko i imię/.....................................................
Date/data/: ...................
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B. To be completed by the authorized Officer:
PCU UK reg number ……………….
On the basis of the information supplied and after consideration of the application it has been decided to
Not/Accept the candidate as a Supporting Member (delete as applicable).
Surname and forename and signature of the person authorised by the executive committee of APE:
Surname and forename:...................................................................................................... Date:...................