Join Online Step 1 of 5 20% Title*First Name*Surname*Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Telephone Save and Continue Later To become / renew as a member To become or renew as a member of the Friends of Leighton House and 18 Stafford Terrace, please tick one of the boxes below. Payments can be made as a one-off annual payment or at a discounted rate for annual or monthly standing order. Membership Type*Standard rateStanding Order discount (annual)Standing Order discount (monthly)Standard rate*£30 Under 30’s£49 Friend£100 Supporter £50 of which is a voluntary donation£200 Curator’s Circle £150 of which is voluntary donationStanding Order discount (annual)*£27 Under 30’s£40 Friend£85 Supporter (£45 of which is a voluntary donation)£190 Curator’s Circle (£150 of which is a voluntary donation)Standing Order discount (monthly)*£2.50 monthly Under 30’s£3.50 monthly Friend£7 monthly Supporter (£45 of which annually is a voluntary donation)£16 monthly Curator’s Circle (£150 of which annually is a voluntary donation) Save and Continue Later Payment Methods*ChequeJust GivingBank TransferPayment Methods*Standing Order (set up on your own online banking)Payment Methods*Just GivingStanding order (set up on your own online banking) Please make cheques payable to the The Friends of Leighton House sent to the address: Jennifer Sage, Friends’ Administrator The Friends of Leighton House Leighton House Museum 12 Holland Park Road London W14 8LZ On submission of this form you will be redirected to our Just Giving page to complete your transaction. Please include your name. Please set up using your own online banking system with the bank details provided below. Use the bank details below with your name as reference: Barclays Bank, Notting Hill Branch Account Name: Phase 3 Account Sort Code: 20-47- 34 Account: 43057356 SWIFT//BIC BARCGB22 IBAN GB72 BARC 2047 3443 0573 56 Save and Continue Later Make a donationDonationNo donationI am interested to learn more about our Leighton’s Circle membership starting at £1000.00I would like to make a donation to the Friends of Leighton House Thank you for your interest. You will be contacted by Jennifer Sage, Friends’ Administrator, in this regard. Save and Continue Later Gift Aid If you are a UK taxpayer, you can help us even more at no extra cost by signing this declaration. As a charity, we can reclaim an extra 25 pence (at current rates) from the Inland Revenue for every pound donated by you.Gift Aid*Yes, I would like the Friends to treat any qualifying subscriptions and/or donations made by me in the past four years and in the future from the date of this declaration as Gift Aid donations.No, I am not a UK tax payer and Gift Aid is not applicable.Signature*Date* Communication By ticking the box, you agree to continuing to receive museum news and invitations from Leighton House. Contact Details: Jennifer Sage, Administrator, Friends of Leighton House, Tel: +44 (0) 20 7471 9155 Email: email@example.com Thank you for your support.NameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.