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Membership Registration Form 2008-2009
(For New Members or Members changing to a new Category)
I wish to apply for Membership of UL Bohemian RFC. I understand that all applications for admission to Membership of the Club shall be made strictly in conjunction with the Rules of the Club. Payment of Membership Subscription shall constitute an agreement by such member to be so bound. I confirm that the personal details below are correct and I consent to these details being held on the IRFU (players only) and on the UL Bohemian Registration Systems.
Please tick
your selected Category
(See here
for details on Membership Categories)
Single
Membership: ____ Couple Membership: ____ Family* Membership:
____ Player Membership: ____
* If applying for Family Membership, it is essential that
you complete a Youth
Registration Form in respect of each Youth
Member and forward to the Administrator with your application and appropriate
subscription.
Personal Details
Membership No: ____________ (Please enter your previous 2007-2008 Number if changing Category)
Family Name: __________________________________________________________
First Name/s: __________________________________________________________
Address: ______________________________________________________________
______________________________________________________________
Date/s of Birth: _________________________________________________________
Occupation: ___________________________________________________________
Company
Name and Address: ____________________________________________
_____________________________________________________________
Home Phone: ____________________________ Mobile: _______________________
Work Phone: ____________________________ Mobile: _______________________
e-mail Address: ________________________________________________________
Signed: ________________________________ Date: _________________________
Payment Details
Payment Method (Please Tick): Cheque Credit/Laser Card
I enclose cheque for €______ or authorise that €______ be charged to the Credit/Laser Card below as payment for my Subscription in the Membership Category selected (Please Tick selected Category):
Single(€150) Couple(€200) Family 1(€225) Family 2(€250) Family 3(€275) Family 4(€295)
Credit Card
Details:
Name of Cardholder (as on Card): ______________________________________________________
Address of Holder (as on Card Statement) _______________________________________________
__________________________________________________________________________________
Card
Type (Please Tick): Visa
Master
Laser
Card Number:
Expiry Date: (mm/yy)
Signed: ____________________________________________ Date: ___________
Name in Block Capitals _______________________________________________
To
apply for Membership or to change your Membership Category,
print the Membership Registration Form and
post with the appropriate Subscription to:
UL
Bohs Administrator
UL Bohemian RFC
UL Sports Arena
University of Limerick