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							                          Oxford Brookes University
                   Coaching and Mentoring Society (OBCAMS)


Membership/Renewal Application Form
Fee: £30.00 per person                  (One year membership)             Date…………………...

Title ……….         Name……………………………………………………………………………...

Organisation...………………………………………………………………………………………

Job Title …………………………………………………………………………………………….
.
Address.……….……………………………………………………………………………………
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
…………………………………………………………………………………………………….…


Telephone number…………………………………Fax number:…………………………….…


Email address……………………………………………………………………………….……..

                             Payment details (Please tick appropriate box)


     Please find cheque enclosed
          (payable to Oxford Brookes University)

     Please debit my credit card
      (Visa/MasterCard/Access/Switch/Delta)


 Card No …………………………………………………………………………………………………………………………..
 Start date …………………………………. Expiry Date ……………….........................................................................
 Issue No (where applicable) ………………….…………………………………………………………………………….….
 Amount £………………………………………………………………………………………………………………………….


 Signature …………………………………………………………………………………………………………………………
 3 digit security no. (on reverse of card)………………………………………………………………………………………..
 Cardholders Full Name..………………………………………………………………………………………………………..
 Billing Address …………………………………………………………………………………………………………………..
 ……………………………………………………………………………Postcode…..……..…………………………………



     Oxford Brookes University reserves the right to alter the programme without notice.

Please complete and return this form to: Hada Moreno, Business Services,
Oxford Brookes University Business School, Wheatley Campus, Oxford OX33 1HX,
Tel: +44 (0) 1865 484534 Fax: +44 (0) 1865 485705 Email: hmoreno@brookes.ac.uk