Membership Application form
Charity name
*
Registered Address
*
Street Address
Street Address Line 2
City/town
County
Eircode/Postcode
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Charity Registration number
*
Registered with the Charities Regulator or The Charity Commission for Northen Ireland
CHY No
Regsitered with the Revenue Commissioners (ROI only)
Company Registration number
With CRO or Companies House
Main Contact Person
*
First Name
Last Name
Position
*
Address, if different from above
Street Address
Street Address Line 2
City/town
County
Eircode/Postcode
Phone Number
*
-
Area Code
Phone Number
Mobile Number
-
Area Code
Phone Number
Back
Next
Name of shops
If different from charity name
Number of shops
*
Membership subscription
*
1 shop €180
2-5 shops €150 per shop
6-10 shops €130 per shop
11-24 shops €120 per shop
25-99 shops €2,950 flat fee
99+ shops €3,250 flat fee
Membership agreement
*
I agree, on behalf of my charity, to pay the membership subscription due in January each year
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: