FROM 1 January 2010 – 31 DECEMBER 2010

(PLEASE USE CAPITAL LETTERS)

Surname (Mr.Mrs.Ms.)………………………………………………………

First Name(s)……………………………………………………………………

Address…………………………………………………………………………….

………………………………………………………………………………………..

……………………………………………Post Code……………………………

Telephone No…………………………………..Date…………………………….

Date of Birth (Essential for Records)……………………………………..

Occupation………………………………..Signature…………………………..

Name of Proposer………………………………Member No………………..

Name of Seconder………………………………Member No……………….

 MEMBERSHIP FEE TO 31 DECEMBER 2010

C. H. Club New Membership (Male/Female)  £………………..(£17.00)

With C.I.U. Affiliated Membership                £………………..(£23.00)

(FEE INCLUDES DOOR ENTRY SECURITY FOR)

TOTAL £……………………

Contact email     admin@carltonhouseclub.co.uk 

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