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BIRMINGHAM SPEEDWAY SUPPORTERS CLUB

MEMBERSHIP APPLICATION FORM 2017

Title

First Name

Surname

Address

Postcode

Tel.        (home)
        (mobile)

.        (h)  _______________________________________
        (m  _______________________________________

e-mail address

Desired Website Username

Date of Birth

Favourite Rider

FOR OFFICIAL USE ONLY

Membership Type

£5 FULL  / £4 CONCESSIONARY

Payment made

£              On ____/____/ 2017

Membership Number

Expires 28th Feb 2018