Membership Application

Title

First Name

Last Name

Email Address

Password

Confirm Password

Telephone

Address

Town

Postcode

Applicant’s academic details

Application Type

Year of entry

Year of leaving

Degree Course (Dept. if PhD or staff)

I offer myself for election to the Agricola Club and agree to abide by the Club Regulations (copy available from the Hon. Sec), I authorise the Club to hold my details on the Club data-base and to publish my name, postal address, and email address in the Journal.

A one-off payment of £50.00 is required for life membership to complete the joining process.

Payment can be made by BACS: Sort Code 30-90-28, Account Number 00028380 please use your name as reference

Once payment has been confirmed you will be notified and your account will become active