100Club Membership Application Form
Form MA11
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Surname *
Forename *
Email *
Address *
Phone number *
Preferred Method of Communication *
Required

I wish to pay Monthly by Standing Order or Annually by BACS

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I am applying for the following number of entries *
Standing Order:- I will complete a monthly standing order authority for the payment selected per month.
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I will commence membership from

 *

I have read and agree with the Club Rules and make this application for Membership on such basis

 *
Required
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