Birmingham Perl Mongers
* Full Name: ___________________________________________________________________
Badge Name: __________________________________________________________________
Badge name will appear on your membership card, that will be printed and given out at our earliest convenience, following your
membership acceptance. Badge Name can be your nickname, IRC handle, real name or any other name, providing it is suitable :)
However, we will still need your real full name, which will be kept private and confidential.
* Mailing Address: _____________________________________________________________
* Postal Code: _________________________________________________________________
* Country: _____________________________________________________________________
Payment: [ ] £25 annual membership fee
[ ] £10 annual membership fee (unwaged or student)
[ ] donation for the sum of £_____________________
Please note that fields marked * are mandatory and must be completed in full.
This application form, together with payment, should be handed to a board member. Payment maybe made in cash or by cheque.
Cheques should be made payable to Birmingham Perl Mongers Limited.
Membership will last for 12 months from the date of payment. Membership acceptance is at the discretion of the directors and
officers of Birmingham Perl Mongers Limited and subject to acceptance of our Terms and Conditions of Membership, which can be
viewed on the Birmingham Perl Mongers website at http://birmingham.pm.org/cgibin/brum.pl?act=hometerms.
[ ] I have read and agree to the Terms & Conditions of Membership.
Membership Number: ______________________ [Official Use Only]
Renewal Date: ______________________ [Official Use Only]
Birmingham Perl Mongers Limited
Company No: 5705899, Registered in England and Wales
15 Graham Crescent, Rubery, Birmingham, West Midlands, B45 9DD, United Kingdom