Application for annual membership
By becoming a member, you will be supporting the regeneration of the Cefn Fforest Miners Institute, and the charity formed to carry out this work. You will also have a say in the future of the institute, it’s provision for the community and how it is run.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
By signing below, you agree to the £10 membership fee and to the terms and conditions of membership detailed on the back of this form.
Add an additional donation towards the upkeep of the institute
prev
next
( X )
GBP
Description
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Should be Empty: