BRISTOL CYCLING CAMPAIGN
                             MEMBERSHIP FORM

              * I want to join the Bristol Cycling Campaign

NAME(S)   ..............................................................

ADDRESS   ..............................................................

          ..............................................................

          ..............................................................

POSTCODE  ..............................................................

TELEPHONE ..............................................................        

E-MAIL    ..............................................................

         £5 Individual                            ..........

         £2 Concession                            ..........
 
         £7 Household                             ..........
   
         and I would like to make a donation of  £.......... 

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EITHER:
I enclose a cheque/postal order made payable to Bristol Cycling Campaign

for the sum of £...........

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OR:
I would like to pay by standing order:
NAME AND ADDRESS OF YOUR BANK/BUILDING SOCIETY

........................................................................

........................................................................

........................................................................

ACCOUNT NUMBER .........................................................

Please pay to the Bank of Scotland, Prince Street, Bristol for the 
account of Bristol Cycling Campaign a/c no. 00143662, sort code 12-05-77

£............. ANNUALLY, STARTING ON (DATE) ............................

SIGNED ..............................  DATE ............................      

NAME in capitals .......................................................

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                        Please return this form to 
                               Eric Booth          
                             13 Alpha Road         
                               Southville          
                            Bristol BS3 1DH       
                                                   (MEMFORM.TXT 14/1/00)