COSTA
Community Organisations of South Tyrone & Areas Ltd
President Grants Homestead, 45 Dergenagh Road, Dungannon, Co Tyrone, BT70 1TW
Tel: 028 855 56880		Fax: 028 855 56881
Email: info.costa@btconnect.com 	Facebook: Board Costa

COSTA MEMBERSHIP APPLICATION FORM

YOUR DETAILS - Please complete the following sections in full … Please supply an email address as a main contact for your group. Note: all Newsletters and information are largely sent out via emailed only.

Group’s Name: …………………………………………………………………………………………………………………………………..

Contact Person & Job / Role title: ……………………………………………………………………………………………………….

Full address & Postcode: …………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………

Telephone Numbers: ….……………………………………………………………………………………………………………………..

Fax No: …………………………………………………………………………………………………………………………………………....

E-mail: …………….………………………………......…   Website: ………….……………………………………………..

1)  Tick the boxes that best describe your group / organisation type

Voluntary Organisation			[  ]		Church Related					[  ]
Community Organisation		[  ]		Private Business					[  ]
Statutory Organisation			[  ]		Network / Umbrella Organisation		[  ]
Social Economy				[  ]		Funder / Intermediary Funding Body		[  ]

Other (please state) _______________________________________________________________________________

2)  Group’s main purpose / activities: ____________________________________________________

________________________________________________________________________________________

3)	Main Area(s) your organisation deals with / works in:

Rural					[  ]		Environmental				[  ]
Urban  					[  ]		Education / Training			[  ]
Health					[  ]		Arts / Leisure				[  ]
Youth					[  ]		Children				[  ]
Men					[  ]		Women					[  ]
Older People				[  ]		Disability				[  ]
Farmers					[  ]		Residents Association 			[  ]

Other (please state) _______________________________________________________________________________

4)  Any other comments / information: ___________________________________________________________

I ………………………………………………………… am authorised by the above group to apply for membership of COSTA Rural Support Network (in accordance with the Charities Act (NI) 2008) and I enclose the annual membership fee of £5.  

Signed: ……………………………………………………….   Date:  .…………………………………………….

WELCOME TO COSTA - THANK YOU!