Leeds Carnegie Supporters Association
MEMBERSHIP APPLICATION
FORM
PLEASE USE BLOCK
CAPITALS!
| Name: |
________________________________________________________ |
| Date of Birth: |
______ / _____ /
__________ |
| Address: |
________________________________________________________ |
|
________________________________________________________ |
|
________________________________________________________ |
|
________________________________________________________ |
| Phone No: |
Daytime: ____________________________ |
|
Evening:
____________________________ |
|
|
| Email Address:
________________________________________ |
| (To be used for LCSA
Newsletter and other LCSA mailshots) |
| Please sign below to
show you agree to abide by LCSA membership rules as specified in the
constitution, and that the LCSA may hold your membership details on
computer. Information will only be used for the administration and
running of the LCSA and will not be passed onto third parties. |
| Signed:
___________________ Dated:
________________________ |
|
ADMINISTRATION USE
ONLY
| Membership Type: |
ADULT / JUNIOR |
Membership No. |
________________________ |
| Date Card Issued: |
______ / _____
/______ |
Date Fees Paid: |
_______ / ______ /
_______ |
| Records Updated
By: |
____________________ |
Updated On: |
_______ / _______ /
_______ |
|
|
COMPLETED FORMS
& SUBSCRIPTIONS (£5 for adults, £2.50 for juniors) SHOULD
BE RETURNED TO: |
| LCSA Membership, 9 Red Vale, Gomersall, Cleckheaton, BD19 4AJ |
|