The Disabled Motorists Federation - Membership Application Form

New Membership Application

Please complete this online form then click the Submit button to pay by your PayPal account or your credit/debit card using PayPal.

Annual Subscription fee is £14.00.

*Title:
*Full Name (First and Last Name):

*House Name/Number:
*Address Line 1:
Address Line 2:
Post Town or City:
County:
*Postcode:

*Home Tel:
Mobile Tel:

*Email:

*Age Group:	Under 25 25-50 50+ Ladies 65+ Men 65+

*Ethnic Origin:	Asian or Asian British Black or Black British African Black or Black British Caribbean Chinese White - British White - White any other background Mixed - White & Asian Mixed - White & Black Any other Not known (Prefer not to say)

Please select one of the following:	Disabled Driver Disabled Passenger Carer of a Disabled Person Non of the above

Please check your details, then click the Submit button to make your secure payment by PayPal. You can either pay using a PayPal account, if you have one, or by credit/debit card.

New Membership Application