2011 Share Application Form

							                                               PONTY RUGBY LTD
                                        SHARE APPLICATION FORM



Title:
First Name:                                                          Tel No:
Surname:
Address:                                                             Date:




       I wish to apply for      ________ Ordinary Shares @ £50 each.

       Total Value £ ________

       Signed: _______________________________ Date: __________________

PAYMENT METHOD
MONTHLY STANDING ORDER:                            PRFC BANK DETAILS
Please tick if form required:                      (for bank payment or Standing Order):
                                                            Sort code: 30 96 72
                                                           Account No: 03283405
                                                                 Ref:   PRFC Share


CASH: £ _______                                    CHEQUE     £____________
(A receipt will be issued)                         Made payable to: Ponty Rugby Ltd



DEBIT/CREDIT CARD                      Please note: AMEX, ELECTRON and SOLO not accepted

Card Type:               _      Card Number:

Expiry Date:                     Security No:                     Issue No. (Switch only):

Name on Card:                          ________

Signed:                         ________           _______         Date: _______________

Please return completed form to:
Share Issue, The Clubhouse, Pontypridd RFC,
Sardis Road, Pontypridd, CF37 1HA

For Office Use               Ref:                 Folio: