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Membership Application
Type of membership
Lifetime Member - I would like to join the British Polio Fellowship and agree to pay a one off joining fee of £25
Would you like to join as a central office or branch member?
Personal details
Title:
Surname: 
Forenames: 
Date Of Birth:  
ex.: DD/MM/YYYY
Email:  
Address: 
Post Code:
Phone Number:
Have you had Polio.
Year Polio Contracted (If applicable): 
Where did you hear about the fellowship?
Ways to pay for Lifetime Membership
Choose your option:
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