Name(s) | : | |||
Badge name(s) (if not as above) | : | |||
Address | : | |||
City/Town | : | |||
County | : | |||
Postcode | : | |||
email (Optional but helpful if we need to contact you) | : | |||
aXXIdental would like to provide PRs in electronic format where possible and convenient. | ||||
Would you prefer to receive | : PR by post | : PR by email (above) | : Link to PR in email | |
(tick as required) | : ___ | : ___ | : ___ | |
Willing for badge name to appear on the web list of members | : Yes / No | |||
Membership type | : Full Attending (£32) | : Concessionary (£16) | : Small Child (£1) | (please enter number required) | : _____ | : _____ | : _____ |
Signed | : | |||
Date | : |
Notes:
Please send completed applications to:
Axxidental,
c/o 15, St. Catherine's Cross,
Bletchingley,
Surrey, RH1 4PX
U.K.