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ASSOCIATION of INTERNATIONAL BRANCHES
LIVERPOOL F.C SUPPORTERS CLUB
CHESTERFIELD & DISTRICT BRANCH
(NORTH DERBYSHIRE REDS)
BRANCH MEMBERSHIP APPLICATION FORM 2010-2011
Membership subscription charges:
Senior Membership (16 and over):-          £12.00  
Junior (Under 16): -                                   £3.00   
Students (full time), O.A.P. & UB40:-       £6.00                                                                                
* Branch bond fee: -                                 £20.00 
*Only One bond fee payment per household is required. ONLY juniors and full time students are exempt.
Membership of the LFC “All Red” scheme is also required, in order that match tickets can be applied for.

*Please complete ALL SECTIONS in BLOCK CAPITALS ONLY.

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SURNAME: ……….…………………………………………….
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FORENAME/S: ……………………………………………………. 
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ADDRESS: …………………………………………………………
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………………………………………………………………………
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POST CODE ………………………  DATE OF BIRTH: …………………….
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HOME TELEPHONE: ……………………………….................... 
   
MOBILE TELEPHONE: …………………………….
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E-MAIL ADDRESS: ………………………………………………………….  
                                        
MEMBERSHIP APPLIED FOR (please circle):
 
SENIOR                     JUNIOR                        STUDENT/O.A.P./UB40 
  
Declaration – I hereby agree to abide by all Branch rules and regulations
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SIGNATURE: ……………………………………………………………….
 
DATE: ……………….
(Parent or guardian to countersign for juniors).
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Proof of identity / address (e.g. Copy Driving Licence, Utility Bill, Student card, etc.) is required when applying for membership. All applications are subject to Branch Committee approval. 
                                   
Please make cheques / postal orders payable to:
L.F.C.I.S.C. CHESTERFIELD & DISTRICT BRANCH   
Return completed application form and proof of identity to:
  Pete Rawson (Branch Secretary)
22 Church Meadows, Calow
Chesterfield, Derbyshire
S44 5BP