Full Name:

________________________________________________________________

Address:

________________________________________________________________

_________________________________________________________________________

Home Tel.:

______________________

Work Tel.:

______________________

Mobile Tel.:

______________________

Home Email:

______________________

Work Email:

______________________

We will only use your address / phone / email details to contact you regarding the London Clarets, and will not pass this information to any third party.

Membership No. (if renewing – on membership card):

___________________________

I wish to join / rejoin* the London Clarets for season 2003 / 2004       (*please indicate)

Rate (please tick):

Adult: £12

Overseas: £15

Concessions: £6*

* In full-time education / unwaged / senior citizen. Please
 provide proof of status (e.g. Student card, birth certificate)

£___________

Optional donation to the London Clarets

We want membership to be as accessible as possible, and for the third season running our membership fees are unchanged. However, donations help us to meet the costs of running the Club and provide benefits such as our excellent magazine. We are very grateful for all donations, however small.           

£___________

Total due:

^£_===========

Please tick if you do not wish to receive magazines – for example, because another family member receives them – this helps us keep costs down

Please print this form and send it with a cheque or postal order (made payable to Burnley FC London Supporters Club) to:

Brent Whittam
4a Pelton Avenue
Sutton
Surrey SM2 5NN

Please do not send cash.

If you are a new member, how did you hear about the London Clarets?
(Please tick one box only and complete additional information where required)

1. London Clarets website

2. Other website (please specify): __________________________

3. Matchday programme – home

4. Matchday programme – away at: ________________________

5. Burnley FC (except website or programme)

6. A London Claret (please state who): ______________________

7. Word of mouth (not from a London Claret)

8. Other (please specify): _________________________________

THANK YOU VERY MUCH FOR YOUR SUPPORT