Socialist Civil Liberties Association
Either print this Form, complete and send as E-mail Attachment to the >> Treasurer Robin Cherney >> OR return completed hard-copy to him, with payment of Membership Fee, by mail to 24 Grace Way Stevenage Herts SG1 5AA APPLICATION FORM
My name is (full) ..............................................................................................................................Address .................................................................................................................................................................................................................................................................................................Contacts (tel) (fax) (mobile) (E-mail) ......................................................................................................................................................................................................................................................Constituency LP ............................................. Party Membership No ..........................................Having considered the SoCLA Constitution, I hereby APPLY for (circle as relevant) >> 
Individual Membership - OR - Affiliated Membership for > (organisation)...................................................................................................................................Address/contact .....................................................................................................................................................................................................................................................................................Representative (name, details) .........................................................................................................Address ..............................................................................................................................................................................................................................................................................................Contacts (tel) (fax) (mobile) (E-mail) ...............................................................................................Constituency LP ............................................. Party Membership No .......................................... I am sending (a) £5 Individual (b) £15 Affiliated Organisation (+ (c) £ ........... donation) = Total £................
to the Treasurer at the above address > cheque payable to the “Socialist Civil Liberties Association” Signed ...........................................................Date ...........................................................