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Please enter your details below. Fields marked with a * are mandatory.
Title:
First Name:*
Last Name:*
Membership Number:*
Please enter zeros before your membership number if less than six digits,
i.e. 1234 becomes 001234
Address Line 1:*
Address Line 2:
Address Line 3:
Address Line 4:
Address Line 5:
Town or City:
County:
Postcode:*                
e.g.    I     P    4              1     E   W
Electronic Signature
   I confirm that I am the member whose details are listed above
         and that I wish to register to vote by post in the East of England
         Co-operative Society's Elections.