Title      E.g.. Mr., Mrs., Ms., Dr.

 Name      

Address:

           



Telephone: 

      Fax: 

    Email: 

 Postcode: 

Are you a new member of MAPE?  Yes   No

School:    

   LEA:    

Region: 

           1 - South Eastern (most of London, Essex, Surrey, Kent, E. Sussex)  2 - West Midlands  3 - Eastern (Cambs., Norfolk, Suffolk)  4 - South West (Devon, Cornwall)  5 - North West (Cheshire, Lancs., Merseyside, Manchester, Isle of Man)  6 - Yorkshire, Humberside  7 - Northern  8 - Great Western (Glos., Avon, Somerset, Wilts.)  9 - North Wales  10 - East Midlands  11 - Southern Counties  12 - Chiltern (Northants, Beds., Oxon., Bucks., Herts.)  13 - South Wales  14 - N. Ireland  15 - Scotland  16 - Éire  17 - Overseas 

Are you a student?  Yes   No

 Year in College: 

         Faculty: 

Institution Name: 

You will be invoiced for £20 (UK) or £20 (Overseas) or £30 (Overseas - airmail) or £12 (Student)

Or give your Credit Card Details:



           ° ACCESS  ° VISA  ° EUROCARD  ° MASTER CARD  Expiry Date:  CARD NUMBER: 

Name and Address of Cardholder:



Title       Eg. Mr., Mrs., Ms., Dr.

Name       

Address:

           

Charity status has been granted and tax relief can be claimed on the membership fee.

This form will be sent to:

Valerie Siviter, (Membership Secretary) val@bethesda.demon.co.uk

Cilgeraint Farm, St. Ann's, Bethesda, Gwynedd LL57 4AX.

Tel: 01248 602655

Leave a message if you like!