Please print out the following and complete the details using Capital letters throughout. Cheques, Postal Orders etc., should be crossed and made payable to The Irish Titanic Historical Society.

Membership applications should be addressed to: The Membership Secretary, The Irish Titanic Historical Society, 4 Fancourt Road, Balbriggan, Co Dublin, IRELAND

Name( use Caps)

Address:

Telephone Number:

(Home):

(Work):

(Mobile):

E-mail address (if applicable):

Occupation: (optional)

Specific Titanic Interests:

Annual subscription enclosed (circle amount):

Ireland -€ 20.00
Gt Britain - £18
Mainland Europe -€ 25.00
USA - $35.00
Rest of world - €35.00

Form of payment:

Date of application:

Signed:

Where did You hear about The Irish Titanic Historical Society?: