Cinema Season Membership Application Form Name: _________________________________________ Address:
_________________________________________ _________________________________________ _________________________________________
Tel:__________________ Email:
_______________________
I would like to be added to the Nerve Centre email list to receive the latest news, events, offers and opportunities (please tick) <INPUT TYPE=\ CHECKBOX > MACROBUTTON HTMLDirect Season Pass Cost: £36 (NO REFUNDS under any circumstances) Please Note: An up-to-date photographic membership card must be shown at the Nerve Centre reception desk before each film screening. A Season Membership entitles you to entry to all screenings in the current cinema programme on a first come basis. Please note screenings are subject to change including cancelation or rescheduling. Please return completed form with a current passport photo to: Nerve Centre, 7-8 Magazine Street, Derry~Londonderry, BT48 6HJ. Tel:028 71260562. www.nervecentre.org ……………………………………………………………………………………….. For staff purposes only: Cinema Season Membership Card
Photo ID
Member Details: Name:
___________________
Address:
___________________ ___________________
Season:
03 Sept – 07 Nov 2012
Exp Date:
07 Nov 2012
Member Signature:
___________________
Please Sign here