Liverpool Century Road Club

  Print out and post to Gen. Sec. address below with membership fee.

Your application will be considered at the next Club night by the Club officials, and if successful, you will be granted immediate membership and your application listed on next months Newsletter.

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I desire to become a member of the "Liverpool Century Road Club" and hereby make application and agree, in the event of being elected, to abide by the Rules & Regulations of the Club (Rule Book will be given on successful membership).

signed

full name with title         

address                        

postcode                      

telephone number         

e-mail address

State previous clubs if any, for how long.

Have you fulfilled all obligations to these clubs?  Yes/No

******If Family Membership, give parent details above and add family member below*********

Family members            full name                                                                      date of birth (if under18)

Membership Fees                                                        Your next subscription is due on 1st November

Joining - Nov to April  (12 months)                                  May to October  (6 months)

Family..................................£25.00                                                     £12.50

Senior (over 18)...................£20.00                                                    £10.00

Under 18....................£10.00                                                              £5.00

                                                               please leave below blank

Approval required by 3 of the following;-

President.........................................................                  Date..................................................

Chairman.........................................................                  Date..................................................

Treasurer.........................................................                  Date..................................................

Gen. Secretary..........................................................         Date..................................................

Cash received £.......................................................          By.................................................................................

Date accepted..........................................................                                                                                        Type of membership..................................................