Membership Application Form
Please type in your information and then print this form .
Send the completed (and signed) form, along with your cheque or standing order form to:
The Membership Secretary, Countryside Ireland,
100, Ballygall Road East, Glasnevin, Dublin 11

E-mail membership@countrysideireland.com

Telephone (01) 8348279 - (International +353 1 834 8279)

Name
Address
Telephone	E-mail
Signature	I agree with the objectives of Countryside Ireland. ............................................................................................................................Date..............................................
Name of Club (If any)
Category: (Please tick)	Adult         Family         Junior        Life

Names of members     (If applicable)	Date of Birth (if under 18)

Annual Subscription Rates

Membership Category	Adult	Family (Husband, wife, and 2 under 18)	Junior (under 18)	Life (Once only.)
Annual subscription	€25.00	€50.00	€10.00	€350.00 (min.)

Please Note:   Countryside Ireland reserves the right to refuse membership.

I enclose a cheque made payable to "Countryside Ireland" for , or
I enclose my completed bankers standing order form for my subscription.  (Click here to view and print a Standing Order form)