Membership Form

Please print the following form and post it to us with your cheque, made out to The Glass Bar. Alternatively click here to pay by PayPal.

Click here to print the form

Contact Details

Email Address:*

    

Salutation:

First Name:*

Last Name:*

Address Line 1:*

Address Line 2:*

Address Line 3:*

Address Line 4:

Post Code:*

Country:*

Home Telephone:

Mobile:

                 

Personal Circumstances

(Please help us to understand our membership profile better and to offer you a better service by answering these optional questions about your personal circumstances)

Number of Children/Dependents:

  

Date of Birth:

  

Profession:

  

Ethnic Origin:

    

Accommodation Type

Rented:

  

Own home:

  

Living with Parents:

  

Other:

    

Recreational Interests

Interests:

    

Average Number of Nights Out Per Month

          

Bars/Pubs:

  

Restaurants:

  

Gigs:

  

Clubs:

  

Groups:

Other:

            
           
                 

Contact Preferences *

Email:

  

Mobile:

  

Post:

        

Newsletter

I would like to receive the Newsletter:

          

Membership Type *

Daily Membership (£1):

  

Membership Level 1(£25):

  

Membership Level 2(£50):