HARWELL LABORATORIES RECREATIONAL ASSOCIATION

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

I hereby apply for: ORDINARY MEMBERSHIP

I authorise:* the deduction of £4.00 from my salary per month as my subscription to HLRA, or as changed from time to time by a General Meeting.

If I wish to cancel my membership, I will return my membership card to the Recreational Association Administrator, who will authorise Salaries/Wages Section to cancel my subscription to the Association.

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

(Block capitals please)

ESTABLISHMENT:* HARWELL / RAL / CULHAM

EMPLOYER:* AEAT / CANBERRA / CNPA / DIAMOND / HPA / JANET(UK) / JCL / NDA / NNL / RSRL / SCION / SERCO / STFC / UKAEA

BUILDING:_______TEL NO.:______________________ PAY NUMBER:_______________ DATE OF BIRTH:_____________

e-mail address:_____________________________________________________________________

DATE:_______________________SIGNED:_________________________________________________

*Delete as appropriate

For office use:

Card no:_______________ Date of issue:_______________ Administrator:_____________