Membership Form     (RIGHT CLICK, COPY AS WORD DOCUMENT INTO BLANK DOCUMENT AND THEN PRINT)

IRISH MASTER ATHLETES ASSOCIATION

MEMBERSHIP APPLICATION

RENEWAL OF MEMBERSHIP
Please complete CLEARLY WRITING IN BLOCK CAPITALS  and forward to the Treasurer along with your payment to;

George Maybury, 28 Hazel Lawn, Dublin 15
Membership fee is €15 per athlete,
Should you wish to pay by standing order, send first part of this form to IMAA and the standing order form directly to your bank.
Irish Master Athletes Association
Name: _____________________________________________
Address: ___________________________________________
___________________________________________
Mobile no: _________________________________________

Landline No ________________________________________

AAI REG NO: (if IRL Club)________________________

CLUB (IRL &NI essential) _________________________________________
E mail address:______________________________________
Date of Birth: _______________________________________
Please tick appropriate item:-
Membership €15 per year  paying cash. Handed to _______________________

Cheque: HANDED to _______________________________________________

 Member paying via standing order.
Signature: _________________________
Standing order to be sent to your bank)
Name: ___________________________________
Address: ________________________________
__________________________________
My account number: ____________________________
Please set up the following standing order from the above account which is to be paid annually each year until further notice as follows:-
Bank : Bank of Ireland, Swords, Co. Dublin. Sort code; 90-07-03
Account name : Irish Masters Athletes Association Account no; 57281763
Reference : Name & Address as above
Commencement date : ____________________
Amount to be debited : €___________

Signature : ______________________________________________________