Title

Mr / Mrs / Miss / Ms

(Delete as applicable)

First Names

Surname

Address

Post Code

E-mail

Date of Birth

Phone Number

I wish to become a member of the Hillingdon Cycling Club and understand that, once accepted, I will receive a copy of the Club’s Rules and should I not be willing to abide by them my subscription will be refunded

Subscription rates are as follows:

                                                                                       Senior Membership                                   £25.00

                                                                                       Junior Membership                                    £13.00

                                                                                       Juvenile Membership                                  £5.00

                                                                                       65+ (Over 65)                                              £20.00

                                                                                       Associate                                                     £13.00

                                                                                       Second Claim                                             £19.00

(if you are joining as a Second Claim member, please provide below the name of your First Claim club)

I enclose a cheque for £..................... payable to Hillingdon Cycling Club

Applicant’s Signature

Date

Send the completed form and cheque to:

                                                                                   Jim Burgin

                                                                                   33 Pinelands Park

                                                                                   Padworth Common

                                                                                   Reading  RG7 4QB