MINI COOPER REGISTER - MEMBERSHIP APPLICATION FORM

(Please complete in CAPITALS)

Surname ____________________________________________________________________ Mr/Mrs/Miss ________

First Names ______________________________________________________________________________________

Partners Name (If joint membership required) ______________________________________________________

Address_________________________________________________________________________________________ 

_________________________________________________________________________________________________  

Post Code ______________________________________________ County___________________________________

Country ________________________________________ Tel. No __________________________________________

email address _____________________________________________________________________________________

How did you first hear about the Mini Cooper Register?_____________________________________________

From whom, or where, did you receive this application form? The internet 

I hereby apply to become a member of the MINI COOPER REGISTER and I agree to abide by its Rules and

Regulations.

I enclose a PO/Cheque (Payable to the Mini Cooper Register) for £_____________________________

(NB Europe/Rest of the World Applications - Sterling Cheques or Credit Cards only please)

ALL APPLICANTS PLEASE COMPLETE THE FOLLOWING

Signed _______________________________________________________  Date ______________________________

I wish to pay by Mastercard/Visa. Please debit my credit card account with the amount £ ____________

My Mastercard/Visa No is |__|__|__|__| |__|__|__|__| |__|__|__|__| |__|__|__|__|

Security Code (on reverse of card) |__|__|__|__| Expiry Date of Card __ | __ / __ | ___

If paying by Mastercard/Visa please complete the following:

Name (as on card) __________________________________________________________________________________

Cardholder's Address _______________________________________________________________________________

____________________________________________________________________________________________________

Please return the completed form to:

Annette Clayson, Membership Secretary,

MCR, 39 Longhope Drive, Wrecclesham, Farnham, Surrey. GU10 4SN UK.