If you would like to join the Congleton & District U3A please complete all the requested details below and our membership secretary will contact you shortly. More Information

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Title	*	MrMrsMsDrMissProfRevOther
Other Title	*
Forename	*
Family Name	*
Housename
House No & Street Name	*
Village
Town / City	*
Post Code	*
Your email Address	*
Repeat email Address	*
Type of Membership		Select Membership Type Full Membership Discounted Membership
Primary Telephone Number	*
Secondary Telephone Number
Emergency Contact Number
Emergency Contact
Full/Discounted Notes
		No Yes  I have an Email Buddy
		No Yes   Gift Aid
		No Yes   Third Age Magazine
		No Yes   National Trust Member
		No Yes   English Heritage Member
		No Yes   Cadw Member
		No Yes Do you have any needs which we should to be aware of?

SECOND MEMBER DETAILS
Title	*	MrMrsMsDrMissProfRevOther
Other Title	*
Forename	*
Family Name	*
Your email Address	*
Repeat email Address	*
Primary Telephone Number	*
Secondary Telephone Number
Emergency Contact Number
Emergency Contact Name
Full/Discounted Notes
		No Yes   I have an Email Buddy
		No Yes   Gift Aid
		No Yes   National Trust Member
		No Yes   English Heritage Member
		No Yes   Cadw Member
		No Yes Do you have any needs which we should to be aware of?

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