BASINGSTOKE COMMUNITY TRANSPORT

Chute House Church Street Basingstoke RG21 7QT Tel: 01256 320501

 

Application to Affiliate

 

Affiliation Number__________

 

Title:    …………………                      (Mr,Mrs,Ms,Miss,Dr etc)

 

First Name:  ………………… Other initials: ……………….

 

Surname:  ……………………

 

Address:  …………………………………………………….…………………..

 

Town:  ………….……….        Postcode:  …………..

 

Telephone No:  ……………… Mobile No: ……………….……………

 

Disabilities :  …………………………………………………. (Any we need to know about)

 

Date of Birth: ………………………………………

 

I Use a walking frame/wheelchair/scooter (Circle any applicable)

 

Important information we should know about

 

 

 

Next of Kin/Emergency contact details:

 

Name:……………………………………………………………………………………………….

 

Address:…………………………………………………………………………………………….

 

Town:………………………………………..   Post Code:……………………………………….

 

Telephone No:……………………………………………………………………………………..

 

Relationship to member if any: …………………………….

 

 I have read and agree to the conditions set out by Basingstoke Community Transport and enclose my £2.00 lifetime affiliation fee

   

 

Signed……………………………………………        Date…………………………………….

   

Print Name……………………………………… (If different to above/signing on behalf of)

   

Email address:……………………………………………… @ ……………………..

     

Registered Friendly Society Number; 22738R

Under The Industrial And Provident Society Act 1965

VAT Registration Number: 688 9066 64

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