100 CLUB APPLICATION FORM

NAME …………………………………………. INITIALS …………. TITLE .………

ADDRESS …………………………………….……………………………………...

………………………………………….….………. POSTCODE …………...……...

TEL …..…………………...… EMAIL…………..……………………………………..

I wish to apply for …………… entries to the RSPB Bexley Local Group 100 Club

and enclose a cheque for £ …………….….. (MULTIPLES OF £12)

Signed ………………………………………………… Dated ……. /……../……..

Please make cheques payable to RSPB Bexley Local Group.

Mr Maurice Ewart
56 Jubilee Way
Sidcup
Kent.
DA14 4JP

Forms to arrive no later than 31st May 2005