(Fill in using block capitals, highlight as necessary)

MEMBERSHIP REQUIRED

Retainer / Bronze / Silver / Gold  



PERSONAL DETAILS



TITLE: Mr / Mrs / Miss / Ms / Other: .....
SURNAME: ............
FORENAMES: ..........
TELEPHONE NO: ...........
EMAIL: ...............................  


MEMBERSHIP NUMBER: ...........

PAYMENT DETAILS



Please choose your method of payment:
CHEQUE: Made payable to RCR Ltd.
CREDIT CARD: Mastercard / Eurocard / Visa / Delta,Switch

Card NO: ..............
Expiry Date: ........  
Issue NO: ...... (switch only)
Signature: ...............
Date: .................  



Send completed form to: 


River Canal Rescue
Freepost NAT11249
Stafford
Staffordshire
ST17 0BR

Refunds will be given at the discretion of the company management. The data protection act 1998 came into force on 1 March 2000 and requires us to obtain your consent to our using the information you provide. By completing this application form you give your consent. This information submitted will not be supplied to any third parties for financial gain or otherwise without your written consent.