If you would like to join the Porthmadog U3A please complete all the requested details below and our membership secretary will contact you shortly. More Information

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Title	*	MrMsMrsDrMissRevRt. Hon.Other
Other Title	*
Forename	*
Family Name	*
Address Line 1	*
Address Line 2
Address Line 3
Address Line 4
Post Code	*
Your email Address	*
Repeat email Address	*
Type of Membership		Select Membership Type Joint Membership Single Membership
Primary Telephone Number	*
Secondary Telephone Number
Emergency Contact Number
Emergency Contact
Other Emergency Contact?
		No Yes  Correspondence in Welsh?
		No Yes   Gift Aid
		No Yes   Third Age Magazine
		No Yes Do you have any needs which we should to be aware of?

SECOND MEMBER DETAILS
Title	*	MrMsMrsDrMissRevRt. Hon.Other
Other Title	*
Forename	*
Family Name	*
Your email Address	*
Repeat email Address	*
Primary Telephone Number	*
Secondary Telephone Number
Emergency Contact Number
Emergency Contact Name
Other Emergency Contact?
		No Yes   Correspondence in Welsh?
		No Yes   Gift Aid
		No Yes Do you have any needs which we should to be aware of?

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