POOLE HEART SUPPORT GROUP

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                   Join PooleHSG

                                                                                                                                                                                                   PRESIDENT

                                                                                                                                                                                                                   Dr. A. A. MCLEOD

 
                                                                                                                                                                                                                  VICE-PRESIDENTS

                                                                                                                                ROBERT PAYNE          MAGGIE RICHARDSON          JIM WAINE          Dr. DI BRUCE          GEOFFREY WALKER

 

 

Joining Poole H.S.G.

 

To join us just print out the form (instructions below), fill it in, then mail it to PHSG Head office  with your cheque enclosed.

We look forward to hearing from you.

 

I wish to become a member of Poole Heart Support Group and enclose my first

Subscription of £8 (if joining between 1st. June and 31st. December ) or

£4 ( if joining between 1st. January and 31st. May ).

I understand that future annual subscriptions will be due on 1st. June and

that this membership includes my partner.

 

Full Name (Mr/Mrs/Miss/Ms (Please print)

……………………………………………………………………………

Address………………………………………………………………..

……………………………………………………………………………

…………………………………….. Postcode…………………….

Date of Birth..........................   Telephone……………………………….

Email……………………………………….................

My subscription is £……...   Date…………………………….

 

Where did you here about us..............................

 

PHSG Head Office: Poole Community Health Centre

                              Shaftesbury Road, Poole BH15 2NT

                                 Telephone: 01202 683 363                         

 

                                      Office use only W/S1/5/2002

                              M/N  .........                           T/R  ...../...../...../             D/B   ....../...../.....

 

To print form:

Edit, select all, Edit copy, open word or similar, right click at cursor, Paste, now print as usual.