HAVE A HEART - SAVE A LIFE
BASIN HEARTWATCH 200 CLUB
APPLICATION FORM
Please return this form to:
The Promoter, Basin Heartwatch 200 Club
The Old School House, Basin Road, Heybridge Basin, Maldon, Essex CM9 4RW
I would like to become a member of the Basin Heartwatch 200 Club.
| Name: | Address: | ||
| Telephone: | |||
| e-mail: |
| Hundred Club Numbers Allocated |
I have filled in and attached a Standing Order form.
I have read and agree with the rules of the Club.
| Signed | ||
| Members's Signature |