Application to become a Fellow, Member or Licentiate

To the Council of the Incorporated Phonographic Society (please use BLOCK CAPITALS in completing this form):

Name ________________________________________ Address  ____________________________________________

_________________________________________________________________________________________________

Telephone No _________________________________ Occupation _________________________________________

I apply to become a ____________________________ of the Incorporated Phonographic Society, in compliance with Clause __________ of the Articles of Association.

I enclose a copy of the following certificate:

Title _________________________________________ Place and Date ____________________________________

Awarding Body ________________________________ Any further details in support of this application:

If elected to membership I hereby undertake to endeavour to promote the objects of the Incorporated Phonographic Society, and I agree to be bound by the Memorandum and Articles of Association as now framed or as hereafter amended.  Prospective members should understand that their details will be held on a database, either computerised or manual, but will not be divulged to any other party.  Please tick here to confirm your acceptance that this is a condition of membership [  ].

Signature _____________________ Date: __________

When completed, this form together with a cheque for £10 Registration Fee plus one year's Annual Subscription, should be sent to Mrs. Mary C  Sorene, 73 Alicia Gardens, Kenton, Harrow, Middx, HA3 8JD.  Please make cheques payable to The Incorporated Phonographic Society.  

For Official Use: