APPLICATION FOR MEMBERSHIP - BLENHEIM CONCERTS

Please print and complete

To:- The Hon. Treasurer,

15 Abinger Road,

Chiswick, London W4 1EY.

NAME: ...............................................................

(Mr., Mrs., Miss)  (BLOCK LETTERS please)

ADDRESS: ............................................................

.....................................................................

Telephone Number: ...................................................

Renewal or New Member?  (Please delete)   

I enclose  Postal Order   )  
  Cheque           )   
  Cash               ) for the following:
     
  Subscription £27.00     ...
  Under 18  £13.50     ...
     
  Donation  ...
     
  Total:     £...

Cheques should be made payable to:- "The Blenheim Music Circle".

If you are willing to display a poster publicising our Recitals please tick here _______.