The High School Zion Road Rathgar Dublin 6 Tel: 01-4922611 Fax: 01-4924427 office@highschooldublin.com
Marina Pearson, Membership Secretary, 80 Castleview Road, Clondalkin, Dublin 22
First Name: ________________________________________
Surname: ________________________________________
Maiden Name: ________________________________________
Address: ________________________________________
________________________________________
Telephone Number: _______________ (H) _________________ (B)
E-mail address: ___________________________
Date of Birth: ___________________________
Date entered School: ___________________________
Date left School: ___________________________
Occupation/Field of Work: __________________________
I enclose: €12.00 Annual Subscription / €50.00 for five years Subscription
(delete as necessary) note: subscription year commences 1st January.
Signed: _________________________
Date: _________________________
