Please print and complete this Application Form in BLOCK CAPITALS

Your Personal Details

Name  ____________________________          Phone No ~ Home  _________________________

Address  __________________________          Phone No ~ Work  _________________________

              ___________________________         Mobile No  ________________________________

              ___________________________         E – Mail  __________________________________

Post Code  ________________      You may / may not * give my home phone number to other members.
                                                                *Please delete as appropriate                                                

Your Interests

[]    Eating Out	[]    Classical Music	[]    Cinema
[]    Theatre	[]    Rock/Pop Music	[]    Ten Pin Bowling
[]    Opera	[]    Country Music	[]    Easy Walking
[]    Ballet	[]    Jazz	[]    Hill Walking

[]    Other (Please specify)  ___________________________________________________

How did you hear about us?

[]    Friend ________________________	[]    Poster __________________________
(Name)	(Where did you see it?)
[]    Publication ________________________	[]    Flyer ___________________________
(Name)	(Where did you see it?)
[]    Other (please specify) ___________________________________________

Membership

[]       I wish to join for six months and enclose a cheque for £ ___________

[]       I wish to join for twelve months and enclose a cheque for £ ___________

Please make cheques payable to The Connexion… and forward with your completed Application
Form to The Connexion…  PO Box 596, Belfast, BT6  0YD.

Signature  ______________________________                  Date  ____________________
……………………………………………………………………………………………………………..........
For Office Use Only                                                       Date Joined  _____________________

Membership Number  __________________             Renewal Due By  _____________________