Chesterfield Cycle Campaign

Membership Form

Full Name__________________________________________________

Address___________________________________________________

Tel number___________________

E mail_____________________________________________________

Membership type (please circle)

Adult 5 Family 10* Unwaged 2.50 Under 18 1

*For Family membership please state all names and ages of children under 18

Family membership is for 2 adults and their children up to 18 years old

_________________________________________________________

Please print this form and send it to the CCC Membership Secretary

9 Ashgate Avenue

Chesterfield

S40 1JB

N.B. These details will be stored on Computer