HARWELL LABORATORIES RECREATIONAL ASSOCIATION

Return to: The Administrator, The Pavilion, Rutherford Avenue, HSIC, Didcot, OX11 0DF

I hereby apply for: ORDINARY MEMBERSHIP

I enclose cheque (payable to HLRA)/cash* to the value of £48 as my subscription for the year ending 30th April 2011

SURNAME(Prof/Mr/Mrs/Miss/Ms/Dr)*___________________FORENAMES:____________________________

EMPLOYER:_____________BUILDING:_______TEL EXTN:____ DATE OF BIRTH:_____________

HOME ADDRESS:_______________________________________________________________________

TEL NO:______________________ e-mail:_______________________________________________

DATE:_______________________SIGNED:_________________________________________________

SPONSORSHIP (for contract employees on Harwell Campus only)

Certified that the above named person is employed at HARWELL/RAL/NRPB/MRC*

By_______________________________(state employer) From:___________ until:__________

Signature:__________________ BLOCK CAPITALS:__________________ DATE:_________ (Manager/Foreman/Chargehand/Supervisor)*

*Delete as appropriate

For office use:
Card no:_______________ Date of issue:_______________ Administrator:_____________