Members

To become a member of our CHARITYHaringey Irish Cultural and Community Centre  (HICCC), please complete the details below and return this form to the General Office on the 2nd Floor at the Centre or post it to the Membership Secretary at the Address stated below.  All the information will be treated in the strictest Confidence and will not be shared with any other organisation. Once your form is received, our Membership Secretary may contact you.  It is important that you complete clearly all the questions below:

Forename: ______________________________         Surname: ________________________________

Date of Birth: _________/_______/___________ Country of Birth: _____________________________

Please tick [   ] if aged under 18.          optional 18 -30  [    ] 31- 50   [ ] 41-60 [    ] 61-80 [ ] 81 +  [ ]

Who recommended you?  A Member [   ]     Other  [    ]     

Full Address: ____________________________________________________________________________________

                ____________________________________________________________________________

Postcode: _________________________________

Telephone Number: ________________________ Mobile: ____________________________

Email Address:  _______________________________________________________________

We may wish to contact you with information about the Charity’s activities and services held at the Centre. If you would like not be to contacted, please tick here [   ]