Leeds United Supporters Club
West London Branch

Name________________________

Address _________________________________________

       __________________________________________
  

Town_______________________Post Code_____________
 

Telephone Number  (home)___________________________

Telephone Number  (work)___________________________


Branch you wish to join :   WEST LONDON
 
The cost to Join West London is £12.50 Per Season.

Please make cheques Payable to LUSC.

Please enclose two passport photographs


Please return this form to:-
Mr J Brackenbury
5 Cornwall Gate
Purfleet
Essex.   RM19  1GE