MEMBERSHIP APPLICATION/RENEWAL FORM

                                     
Please complete in block capitals

Surname:

Title:

Forenames:

Address:

Town:

Post Code:

Tel No:

Email: *

*By giving us your email address you are agreeing to receive communication and information from us.

We will not pass your personal details to third parties without your explicit consent.

Age Group:
Please tick appropriate box.

16 - 30

31 - 45

46 - 60

Over 60

£5.00 if aged 22yrs and under

Date of Birth:

I enclose my subscription, minimum of £25.00 per membership. Please tick appropriate box.

£5.00
(Friend/Young Member)

Under £25
(Friend)

£25.00
(Member)

£30.00
(Member)

£40.00
(Member)

Other

I enclose cash/cheque (made payable to STAFFORD CONSERVATIVE ASSOCIATION)

I would like to pay by standing order and have completed the form below

Signed:

Date:

        Changes to Membership Subscriptions: