Join Us | Old Southeronians' Association

OLD SOUTHERONIANS' ASSOCIATION

MEMBERSHIP APPLICATION FORM

First names

Last name

Date of Birth

Day

Month

Year

Nearest station

Address

Phone (landline)

Phone (mobile)

Marital status

Spouse/partner's name

Spouse/partner's date of birth

Day

Month

Year

Date of marriage/civil partnership

Day

Month

Year

Employer, or Last Employer if retired

Department, Position Held and Location

Date of retirement

Day

Month

Year

Which Branch do you wish to join?

Croydon and SE London

London West

Sussex

Wessex

Date of application

Day

Month

Year

I wish to join the OLD SOUTHERONIANS' ASSOCIATION.

The ONE-OFF life membership fee of £20 (or £10 if retired before 6th April 2005) should be paid by Cheque or BACS to:

Account Name: Old Southeronians Association

Sort Code: 60-16-03

Account 13975358

Your membership will be confirmed upon receipt of both your payment and this application form fully completed.

If paying by cheque, please post it to:

Claire Wickes, Membership Secretary OSA,

85 Larkspur Drive, Burgess Hill RH15 0UL

DATA PROTECTION

The personal details you have provided above will be recorded on a computer and used solely for communication with you by this organisation including the branch you have chosen to join. Your personal details will NOT be passed to any third party (including other members) without your permission. By clicking the Submit button below, you agree to the above Data Protection conditions.