Submitted by Secretary's Forename  * required Reason for change Please select reason Change of Address Death Resignation Cessation Exclusion Honorary Membership	Secretary's Surname  * required Conclave Please select Conclave Cockcroft, 25 Champion, 26 Supera Moras, 49 Freeman, 57 Earl of Harewood, 71 Fraternity, 75 Bury, 80 Roses in Concord, 185 E.L. Prov Officers, 212 John Walter Chitty, 215 Forest of Pendle, 219 Roche Valley, 252 Robert Burns, 368 Dr.J.E. Glover
	Forename(s)  * required Address	Surname  * required Date of Death Date of Resignation Date of Exclusion Date of Cessation Date of Hon Membership
Postcode
Telephone
email