westmidlandslupus.co.uk

LUPUS UK

MEMBERSHIP APPLICATION FORM

(BLOCK CAPITALS PLEASE)

Mr/Mrs/Miss/Ms/Other……………………………………………………First name …………………

Address……………………………………………………………………………………………………….

………………………………………………………………………………………………………..

………………………………………………………………………………………………………..

………………………………………………………………………………Postcode…………….

Date of Birth…………………………………………………………………………Tel No………………..

I wish to become a member of LUPUS UK and enclose my cheque/PO payable to WEST MIDLANDS LUPUS GROUP for:

£……………(£10 per person)

£……………(£15 Joint Membership – 2 people at same address)

£……………(Donation if wished – thank you)

£……………Total

Please return to:

WEST MIDLANDS LUPUS GROUP

8, Legge Lane

Coseley

West Midlands

WV14 8RQ