Please print this page and return it with your cheque to the address below.

Membership / Donation Form

Date: ________________________________________________________

Name: _______________________________________________________

Address:______________________________________________________

_____________________________________________________________

Postcode: ____________________________________________________

Tel No:_______________________________________________________

Email:_______________________________________________________

Please tick appropriate boxes:

Membership (£5.00 per household)

I / we do not want any of the above details published in the groups own list.
I / we do NOT require our own copy of the group's newsletter

Donation: £_____________________________________________

Cheques should be made payable to "Chepstow and District Friends of the Earth"

MEMBERSHIP QUESTIONNAIRE
(optional)

Are you interested in becoming actively involved in any of the following topics?

Please tick appropriate box(es):
Deforestation
Recycling
Energy conservation
Protection of wildlife habitats
Transport
Water
Control of toxic waste
Air pollution
OTHERS: (please state)

Can you offer transport to meetings or other events for members? YES/NO

Do you need transport to meetings? YES/NO

Do you have any particular skills; contacts; experience; or access to resources that you feel would help the local group? YES/NO

Thank you. Please forward to:
Chepstow Friends of the Earth
c/o 14 The Paddock
Chepstow
Monmouthshire
NP16 5BW