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Membership Form
Title:
Forename(s
Surname
Address line 1
Address line 2
Town
County
Postcode
Tel. (Home)
Tel. (Work)
Tel. (Mob)
Email address
Membership Type
Regular £20
Student £10
Pensioner £10
Optional donation amount £
Are you on the electoral register in the UK? Yes No
Please mark the checkboxes below, if you can assist in any way...
Stand as local councillor
Stand in General Election
Serve as election agent
Serve on committee
Go leafletting
Help man a stall
Do radio phone-ins
Write articles
Research a topic
help man telephones etc, during campaigns

Please print two copies of this form.
Keep one for your records, and send the other (along with your cheque) to the following address:

Peter Lindsay, UKIP (Reigate, Epsom and Mole Valley) Treasurer,
P.O. Box 497, Redhill RH1 1XH

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