Print the blank form off and then fill in the form
Please complete the slip below and send together with
a stamped addressed envelope and a cheque
made payable to 'Dewsbury & District Third Age' to
Mrs M Urquhart, High View, Longcauseway, Thornhill, Dewsbury, WF12 0RG
Membership fee £6, covers the period 01/04/10 to 31/03/11
Dewsbury & District Third Age (Membership Registration Form)
Membership No. ............................(Registrar will enter the number)
Title ............ Surname ....................................... Forename ............................................
Address ............................................................................................................................
..........................................................................................................................................
Post Code .................................. Phone No. ..................................................................
Signed ............................................................................. Date .......................................
If you pay income tax and would like Third Age to claim Gift Aid on your £6 membership fee please sign below
Signed ................................................................. Date .......................................................
email address ........................................................................................