<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"> <HTML> <HEAD><TITLE>ACWA - Membership Application Form</TITLE> <META content="text/html; charset=utf-8" http-equiv=Content-Type><LINK rel=stylesheet type=text/css href="normal.css"> <META name=GENERATOR content="MSHTML 8.00.6001.23588"></HEAD> <BODY bgColor=#ffffff> <FORM method=post action="#"> <H4 align=center>ACWA Membership</H4> <H3 align=center>Application / Update&nbsp;Form - 2017</H3> <TABLE border=0 cellPadding=0 width=620> <TBODY> <TR> <TD height=17> <P align=center><EM>List Family Members</EM> </P></TD> <TD height=17><STRONG>Surname:</STRONG></TD> <TD height=17><STRONG><FONT face=Arial>Forename (s) :</FONT></STRONG></TD></TR> <TR> <TD></TD> <TD height=17><INPUT size=30 name=textfield1></TD> <TD><INPUT size=30 name=textfield2> </TD></TR> <TR> <TD></TD> <TD><INPUT size=30 name=textfield3></TD> <TD><INPUT size=30 name=textfield4></TD></TR> <TR> <TD></TD> <TD><INPUT size=30 name=textfield5></TD> <TD><INPUT size=30 name=textfield6></TD></TR> <TR> <TD></TD> <TD><INPUT size=30 name=textfield7></TD> <TD><INPUT size=30 name=textfield8></TD></TR> <TR> <TD></TD> <TD><INPUT size=30 name=textfield9></TD> <TD><INPUT size=30 name=textfield10></TD></TR> <TR> <TD></TD> <TD><INPUT size=30 name=textfield11></TD> <TD><INPUT size=30 name=textfield12></TD></TR> <TR vAlign=top> <TD> <P align=right><STRONG>Address:&nbsp; line 1:</STRONG></P></TD> <TD colSpan=2><INPUT size=67 name=textfield20a></TD></TR> <TR> <TD> <P align=right><STRONG>line2:</STRONG></P></TD> <TD colSpan=2><INPUT size=67 name=textfield20b></TD></TR> <TR> <TD> <P align=right><STRONG>line3:</STRONG></P></TD> <TD colSpan=2><INPUT size=67 name=textfield20c></TD></TR> <TR> <TD> <P align=right><B>Post Code:</B></P></TD> <TD colSpan=2><INPUT size=30 name=textfield21></TD></TR> <TR> <TD> <P align=right><B>Tel. No. (inc STD code):</B></P></TD> <TD colSpan=2><INPUT size=30 name=textfield22></TD></TR> <TR> <TD> <P align=right><STRONG>Email:</STRONG></P></TD> <TD colSpan=2><INPUT size=67 name=textfield23></TD></TR> <TR> <TD> <P align=right><STRONG>Other Info &amp;/or <BR>Query:</STRONG></P></TD> <TD colSpan=2><INPUT style="WIDTH: 437px; HEIGHT: 44px" size=67 name=textfield24></TD></TR></TBODY></TABLE> <P><B>Please enrol me/us as member(s) of A Coventry Way Association.</B></P> <P><STRONG>Fee is &#163;3 per family.<BR></STRONG>&nbsp;&nbsp;<EM>Select button below to indicate which is appropriate</EM><BR>&nbsp;<INPUT value=No type=radio name=Cheque> <STRONG>I enclose cheque for &#163;3 payable to "ACWA" <EM>or</EM> </STRONG><BR>&nbsp;<INPUT value=No type=radio name=Cheque> <STRONG>I have already paid or I am an Honorary Member, and enclose form only as update of information</STRONG></P><PRE></PRE> <P>&nbsp; <B></B></P> <P><B>Signed</B>&nbsp;&nbsp;..............................................................<BR><B>Date&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</B><INPUT size=27 name=textfield26></P> <P><BR>Please print and return completed form to :</P> <P><B>Ken Nicholas,<BR>ACWA Membership Secretary,&nbsp;&nbsp; <BR>24 Columbia Gardens, <BR>Bedworth, <BR>Warks CV12 9EF</B></P> <P>Read about the <A href="acwa_aims.html">Aims of ACWA</A>, or&nbsp;go to <A href="index-2.html">ACW Home Page</A>.&nbsp;</P> <P>Any queries either:<BR><STRONG>&nbsp; Phone 024 7631 3681</STRONG> <STRONG>or<BR>&nbsp; Email </STRONG><A href='mailto:webmaster@acoventryway.org.uk?subject="ACWA Membership"' ACW Website??? Membership???><STRONG>webmaster Subject: ACWA Membership</STRONG> </A></P></FORM> <P>&nbsp;</P></BODY> <!-- Mirrored from www.acoventryway.org.uk/acwa_maf.htm by HTTrack Website Copier/3.x [XR&CO'2014], Fri, 24 May 2019 13:57:06 GMT --> </HTML>