Membership Form Rev1 3

							                    Birchmoor W.M.C. Membership Form                                                                       Birchmoor W.M.C. Membership Form
  * Date                                                                                                 * Date
                                                          *   Denotes Mandatory field                                                                            *   Denotes Mandatory field

  * Surname                                           * Forename                                         * Surname                                           * Forename



  * Address                                                                                              * Address




                                                                        * Post Code                                                                                            * Post Code




  * Date of Birth                         * Occupation                                                   * Date of Birth                         * Occupation



  * Tel Number                            Email Address                                                  * Tel Number                            Email Address




  Proposed by                                        Print name                                          Proposed by                                        Print name




  Proposed by                                        Print name                                          Proposed by                                        Print name



Received the sum of £5.00p Membership Fee + £3.50p Yearly subscription.                                Received the sum of £5.00p Membership Fee + £3.50p Yearly subscription.
Fees will be returned in full if this application is declined.                                         Fees will be returned in full if this application is declined.
Members Subscriptions are due on the 1st January each year.                                            Members Subscriptions are due on the 1st January each year.

    ACCEPTED                                         DECLINED                                              ACCEPTED                                         DECLINED


                 …………………………………..                               Mrs B HAYLING (Club Secretary)                           …………………………………..                               Mrs B HAYLING (Club Secretary)



Information supplied will not be disclosed, in line with C.I.U.'s Privacy Policy & the Data            Information supplied will not be disclosed, in line with C.I.U.'s Privacy Policy & the Data
Protection Act 1998.                                                                                   Protection Act 1998.
                                                                                              Rev1.3                                                                                                 Rev1.3