The Disabled Motorists Federation

Charity No. 1012874

Membership Form

*Age Group
Under 25  25 - 50  50+
Over 65 Ladies  Over 65 Gentlemen
*Ethnic Origin
Asian or Asian British  Black or Black British African
Black or Black British Caribbean  Chinese
White - British  White - White any other background
Mixed - White & Asian  Mixed - White & Black  Any Other
Not Known/Prefer not to say  

Please PRINT this page.  Enclose a cheque for £12 for your yearly subscription made payable to DMF & forward to:-
Mr J. Killick
C/o Chester-le-Street & District CVS Volunteer Centre,
Clarence Terrace
Chester-Le-Street
Co.  Durham
DH3  3DQ
(Alternatively submit the form and forward a cheque to the above address.  When the cheque clears then membership will be valid)