NAME_________________________________________________________________

ADDRESS______________________________________________________________

_______________________________________________________________________

TEL___________________________________________________________________

FAX___________________________________________________________________

EMAIL ________________________________________________________________

I WISH TO BE A MEMBER OF THE WORKING GROUP________________________

I WISH TO BE A MEMBER OF A SPECIAL INTEREST WORKING GROUP ________________

THE WORKING GROUP WHICH AREAS I AM INTERESTED IN ARE:

Leisure/Recreation/Health and wellbeing _______________

Housing _________________

Transport and Traffic ____________

Community and its Facilities _____________

Crime ____________

Countryside and the Environment ___________

Community History/Our church and chapel ____________

Other _____________

I CAN OFFER THE FOLLOWING SKILLS / EXPERIENCE:

Computer/desktop/web skills ____________

Financial skills _____________

Designing questionnaires ____________

Delivering collecting information ____________

Knowledge of local history ____________

Knowledge of local services ____________

Other skills/experience _____________

Signature………………………………….Date………………………………….

Please cut and paste this template into an email message and send it to us at : bsd-parishplan@hotmail.co.uk or drop it into the Post Office/Shop in Bradfield Southend marked for the attention of the "Parish Plan Working Party"