I/We, the undersigned, wish to put forward my/our name(s) as prospective members(s) of the above mentioned club as laid down in the Clubs handbook and submit my/our name(s) hereunder:

Title (Mr/Mrs/Miss/Other 　　 :.........

(BLOCK LETTERS)

Name(s)...................................................................................................................................

(BLOCK LETTERS)

Signature(s)　 ...............................................................................................................................................

Address.....................................................................................................................................................................................................................................................................................

Postcode.....................................

Telephone number.............................................................................................

Email address....................................................................................................

Where did you obtain your Bull Terrier?　 ........................................................................................................................................................................................................................

..................................................................................................................................................

Proposers signature ....................................................................................

Seconded by (BLOCK LETTERS) ....................................................................................

.................................................................................................................................................

Seconder .signature .............................................................................................

Subscription rates (to accompany application)

£5 single/joint/overseas

Please make cheques and postal orders payable to; The Northern Provincial Bull Terrier Club

Should you object to the club holding your membership record on computer, please advise membership co-ordinator by letter and your records will be recorded manually in accordance with the Data Protection Act.

To Be Completed by the Club;　 　.