Jilly's Rockworld Membership Application

JILLY'S ROCKWORLD - HOME OF MANCHESTER'S ROCK & ALTERNATIVE COMMUNITY

JILLY'S ROCKWORLD Membership Application
Please complete all details
Information is for Rockworld Membership purposes ONLY

Title

Mrs

Miss

First Name
Surname

Gender Male Female

Date of Birth (dd/mm/yy)

Age 18-21 22-25 26-30
31-35 36-40 Over 40

I am already a member Yes No
Membership No

E-mail Address

House/Flat Number

Street

Town

City

County

Postcode

Note: Member Card is posted out to you

I visit Jilly's:
Every night Every week Most weeks
At least once a month Occassionally

I prefer: Thursday Friday Saturday

I prefer: room 1 2(Main) 3 4

I like to see live bands:
Regularly Ocassionally Never

Yes, I would love to receive news of events, promotions, special offers, competitions, and members discounts

FORTHCOMING EVENTS:

Valentines Special.
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NETWORKING.....

Note: When you submit you should be taken to Thank You page - if not please re-submit