Cleveland Hedgehog Preservation Society

                   Membership Application Form


Title.................... Forename...................................


Surname..............................................................

               
Age if under 18....................

       
Child 1........................... Child 2...........................


Child 3........................... Child 4...........................


Address .............................................................                                


Town ................................................................                                  


County ..............................................................


Post Code ...........................................................


Telephone ...........................................................


Email Address .......................................................

Initial Application [ ]         Renewal [ ]

Change of Details   [ ]

I enclose membership fee of £.............
               
Single £3.00	        Family £5.00
Group up to 10 £5.00	Group over 10 £7.50

Cheques payable to CHPS please.

Please return your completed form and remittance to:

Mr Chris Firth

9 Richmond Crescent, Billingham, Cleveland, TS23 2JP

Membership Details are kept on computer and are for Society use only.
If you have any objections please tick here [ ]