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