1. Telephone Home/Mobile
BA CLUBS MEMBERSHIP FORM – COMMUNITY/ASSOCIATE
APPLICANT DETAILS Mr
Mrs
Miss
Other
(relative of another member – specify)
Surname
Address
First Name(s)
Telephone Home/Mobile
Date of Birth
Male
Female
CLUB MEMBERSHIP
Heston (Imperial College)
South Wales
Newcastle
BAMC
BAAE
BAIE
Direct Debit Payment
Regions
Retired
Annual
Gatwick
Student (f/t education)
Monthly
Scotland
ADDITIONAL SUBSCRIPTIONS
Section (specify)
Section (specify)
Direct Debit Payment
Annual
Heston Gym
Note: A separate direct debit is required for each subscription
Monthly
Lottery
AUTHORISATION
I hereby declare that the information I have given is to be true and that I agree to be bound by the Rules of the Club. Personal data provided by you will be held on computer for the purpose of administration and will be used in accordance with the provisions of the Data Protection Act Please tick here if you do not wish to receive direct marketing from the Club
Signature
Date
OFFICE USE ONLY
ID No
DD £
DD £
CB No
DD £
Initials