MEMBERSHIP PAGE I would like to become a member
Please print all details in this box in BLOCK CAPITALS Mr Mrs
First name(s) Surname Tel no
Please tick if we can contact you by email
How did you hear about signing up to become a member? Would you like more information about opportunities to be involved with us?
Please enter my name on the register of members of the organisation. Signature
In the event that the company stops trading while I am a member (or within one year of my ceasing to be a member) I will contribute to the assets of the company a sum not exceeding £1 for payment of the liabilities of the organisation.
It would be helpful to have some information for our records. This will be protected by the Data Protection Act. We will not share this information with anyone (unless we are required to under law).
Date of birth Gender: Male Female (please tick) How would you describe your ethnic group? (please tick one box) White: British Irish Other Mixed:
White & Caribbean
Asian or Asian British: Black or Black British:
White & Black African Chinese or other ethnic group:
Indian Pakistani Caribbean African Chinese
Do you consider that you have a disability?
If yes, please give details Please tell us your fi rst language
No PLEASE SUPPLY WITH BLEED When you have completed this form please return it to any member of KCTMO staff or post it to:
The Company Secretary, Kensington & Chelsea TMO FREEPOST RLYX-BE2B-CLYB, 292a Kensal Road, London, W10 5BE TMO USE ONLY
Verifi ed eligible by ______________________ Occupancy ___________ Date ____/____/________ Membership no ____________________ Date entered ____/____/________ Occupancy Key: Tenant = T Leaseholder = LH Non Resident Leaseholder = LT
I confi rm that I am over 18 years old and the named tenant, leaseholder or freeholder of a property owned by RBKC and managed by the TMO.
Ms Other Address
White & Asian Other
You can also fi ll out this
form online at kctmo.org.uk
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