Email
*
example@example.com
Name
*
First Name
Last Name
Birth Date
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
January
February
March
April
May
June
July
August
September
October
November
December
Month
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
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1964
1963
1962
1961
1960
1959
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1955
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1952
1951
1950
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1948
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1945
1944
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1942
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1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Occupation
*
Main Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Street Address
*
Town/City
*
County
*
Please Select
Blaenau Gwent
Bridgend
Caerphilly
Cardiff
Carmarthenshire
Ceredigion
Conwy
Denbighshire
Flintshire
Gwynedd
Isle of Anglesey
Merthyr Tydfil
Monmouthshire
Neath Port Talbort
Newport
Pembrokshire
Powys
Rhondda Cynnon Taf
Swansea
Torfaen
Vale of Glamorgan
Wrexham
Other
Post Code
*
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Next of Kin
NOK Name
*
First Name
Last Name
NOK Phone Number
*
Please enter a valid phone number.
Relationship
*
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Order your Blood Bikes Wales HI-Vis
What size Hi-Vis do you need?
*
Please Select
S
M
L
XL
XXL
XXXL
Other
If "Other" please let us know
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Publicity Materials
From time to time Blood Bikes Wales may wish to use photographs that have your image on them. Please tell us whether you agree to us using your image or not?
This excludes your ID photo, which has to be used to produce your Blood Bikes Wales ID.
*
Yes, I give permission to use my image
No, I do not give my permission to use my image
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Member Declaration
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My Products
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Blood Bikes Wales Membership Fee
£
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
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Last Name
Credit Card Number
Security Code
Card Expiration
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