Please confirm whether you are a REPs Member or a Club / Facility employing REPs Registered Instructors.

Clubs will receive 350 Referral Flyers and 2 Plaques for displaying in the reception. Individual members receive 50 Referral Flyers.

* Membership Status (please tick)	Individual REPs Member:   Club / Facility Employing REPs Registered Instructors
REPs Membership Number (for Individual REPs Members)

Please provide your contact information. For clubs / facilities please ensure you include your phone number, email and web address:

* First Name
* Last Name
Position
Company Name
* Address 1
Address 2
* Town / City
County
* Post Code
(Company) Phone No
* (Company) E-mail
(Company) Web Site

* mandatory fields

Please confirm which campaign materials you wish REPs to supply:

REPs Club / Facility Plaque - Clubs, Facilities, Businesses only (2)
Referral Leaflets - Individual Members (50), Clubs, Facilities, Businesses (350)

Confirmation:
In ticking the box below you are confirming your wish to be included within the REPs Awareness campaign 2008 with the understanding that marketing materials are supplied only to active REPs members and/or Clubs / Facilities that employ REPs registered instructors.

I confirm my wish to be included within the awareness campaign

Today's Date (dd/mm/yy):