You may use this form to join the WLBN or if you are an existing member, renew your membership. Your submission will be saved and you should send a cheque for £30 for the period up to 31st March 2011 to: David Mills, WLBN Treasurer, Copsham House, 53 Broad Street, Chesham, Bucks, HP5 3EA. Please make cheques payable to the West London Business Network. To pay with Paypal click the button below (cost includes fee of £1.50 for making a PayPal payment), total payable is £31.50 through Paypal:

For new members please complete all fields below If any member wishes to offer special business terms to WLBN members please complete the "Price structure, discounts and special terms for WLBN members" field. SECTION A: Contact details

First Name: *

Last Name: *

Company Name: *

Address 1:

Address 2:

Address 3:

Postcode:

Telephone:

Fax:

Mobile:

Email: *

Type of Business / Description of Products and Services:

Price structure, discounts and special terms for WLBN members:

Type of Membership: *

Individual

Business

I wish to register as an *INDIVIDUAL / BUSINESS. If no preference is indicated membership will be registered as an Individual.

Application Type: *

Join

Renew

I wish to join / renew membership of the West London Business Network.