1.    MR / MRS / MISS (delete as applicable)                              

2.    CHRISTIAN NAMES ………………………………………………………………………              

3.    SURNAME                  ………………………………………………………………………

4.    ADDRESS                   ………………………………………………………………………

                                             ……………………………………………………...POSTCODE  ………………

5.    TEL. NO.                      ……………………………………...   

6.    E MAIL                        ………………………………………

7.    DATE OF BIRTH       ………………………………………

8.    MEMBERSHIP CATEGORY APPLIED FOR  :  (Please tick as appropriate)

LOCAL     (      )       Who reside or have a second home for which they are accountable for council tax and not used for
                                   financial gain, within a twenty-mile radius of Penrith Post Office (note; all correspondence will be
                                   sent to local address). Caravans or mobile homes on sites that do not have a full 12 months residential licence are not included.

COUNTRY     (       )      Resident outside this radius

9.    MEMBERSHIP AGE CATEGORY APPLIED FOR:  (Please tick  as appropriate)  

SENIOR     (      )       Over the age of 21 on 15^th January during the present season

JUNIOR     (      )     Aged 21 years and under on 15th January during the present season    

SENIOR CITIZEN     (      )       Over the age of  65 (men &women) on 15^th January during  the present season
                    
REGISTERED DISABLED     (      )       Please provide written evidence.  A photocopied document is acceptable
               
10.     Please tick     (       )      if the married couples rate is applicable (see subscriptions)

11.     Proposed by:
Full name AND signature of existing member …………………………………………...  
                                                                                ……………………………………………
12.     Seconded by:
Full name AND signature of existing member ………………………...............................  
                                                                                ……………………………………………

13.     How did you hear about the Association ?  (Please specify which advert if applicable)                        ………………………………………………………………………………………………………
If you do not know any existing members but you wish to apply for membership, please write and give your reasons for wishing to join Penrith Angling Association together with some details about yourself.  This will enable the committee to consider your application, which we hope, will be successful.
PLEASE RETURN THIS FORM TO:  Mr A Dixon, Honorary Secretary, Penrith Angling Association, 3 Newtown Cottages, Skirwith, Penrith, Cumbria  CA10 1RJ  (Please do not send any payment with this form)                     

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