Xll 



FORM B. 



Sir, 19 . 



I have the pleasure to inform you, with reference lo 



your application dated the , that yoa have 



duly been elected a of the Victoiua Ixstitutk, ok 



Philosophjcai. Sociktv op Gkkat Britain-. 



I have the honour to be, Sir, 



Your faithful Servant, 



To : Hon. Sec. 



FOIIM C. 



(^Banhers) Messrs. 



* Please pay Messrs. Ransom, Bouverik, &:■ Co. my Annual 

 Contribution of Two Guineas to the VICTORIA INSTITUTE, 

 due on the 1st of January, 19 , and the same amount on that 

 day in every succeeding year, until further notice. 



I am, 



Your obedient Servar.t, 



.19 



If fcliis Form he used, ))l(iiiso iuld voiir Sigiialure, Banker's Nuinc, and the 

 Dats, and return it to tlie Oilier. Ailelplii I'eriMce. llecciiit -stump rt'iiuirod. 



* Tlie above is tlie form for Members. Tlie form for Assoeiutes is the same 

 except tliat tlie Subscription stands as " Oni: GriNEA." 



