Leatherhead AHEAD - REGISTRATION FORM

Moving our town forward - together
PO Box 240, Leatherhead, Surrey KT22 8YQ
Phone (01372) 378125 or 378604 e-Mail: leatherheadahead@aol.com

please print this, complete it and return it to the address above

I / We wish to register as a supporter / supporters of Leatherhead AHEAD.

PLEASE WRITE IN CAPITAL LETTERS

Name(s): Mr / Mrs /Ms (delete as appropriate)

Address:

Post code:

Tel No:

e-Mail:

I / We wish to see access and convenience restored to our town for everyone.

I / We wish to make a donation of £2 / £5 / £10 /£ ...... towards the cost of the campaign to restore access and convenience to our town.

(Please make cheques payable to Leatherhead AHEAD)

All named above to sign please:

Date: