Application form : Workers' Circle Friendly Society
Object
Application form
Object number
1994.310
Physical Description
Application form for the Workers' Circle Friendly Society
Associated Organisation
Material
Paper
Dimension
Width: 210mm
Height: 340mm
Height: 340mm
On display?
No
Inscription
Registered No_______________________for the (-) of the General Office.
No. In Division_________________
Rase of Contribution_____________________________
(Including)
____________________________________________________________________
WORKERS’ CIRCLE FRIENDLY SOCIETY
REGISTERED NO. 1495 LONDON
FOR FRIENDLY SOCIETY AND EDUCATIONAL PURPOSE
DIVISION No_____________
FORM OF APPLICATION FOR MEMBERSHIP
Full name of candidate___________________________________________
(Black Capital Letters)
Full postal address____________________________________________________
(All questions must be answered in words)
Date of Admission______________________________
QUESTIONS
1. When were you born?
2. Give your age next birthday.
3. What is your employment?
4. State if married or single.
5. If married, how many children?
6. How many brothers have you?
7. How many sisters?
8. Are your parents living?
9. Are you is good state of health, and do you
ordinarily enjoy good health?
(s) give date and nature of last illness.
10. Is your wife in good health? If not, give
particulars of nature and duration of (-).
11. Has any Parent, Brothers or Sisters suffered
from fits, (-) or engagement of
mind? If to, give particulars.
12. Are you a member of any other Benefit Society?
If so, state particulars
13. Are you a member of a Trade Union?
14.Have you ever been a member of this Society?
If so, state number of Division.
15. Have you ever been refused admission to this
Society? If so, state reason for refusal.
16. Under which scale of Benefit do you wish to join?
17. In the event of your death, to when shall your
Death Benefit, if any, be paid.
CANDIDATES ANSWER
DAY MONTH YEAR
(-) : An (-) ever 29 years
of age (-) prodvice confidence of birth
or other (-) (-) of age)
Name_____________________________________________________________________Address__________________________________________________________________________________________________Relationship________________________________
DECLARATION TO BE MADE BY THE CANDIDATE
1, the undersigned, declare the aforesaid answer to be true. I agree that the same and this Declaration shall form the
basis of the Contract between myself and the WORKERS’ CIRCLE FRIENDLY SOCIETY ; i further declare that if admitted a
member of this Society, and as any time it should be found that the information given herein upon which I have been admitted
is (-), and that I have withheld anything, the knowledge or which would have presented my gaining admission to the Society,
the Society shall then he at liberty an canced my membership and that I shall forfeit all claims at the funds of the Society.
I also agree to be bound by all the rules of the society. As to benefits applicable to members joining the Society after the
31.12.44. I further agrees to your Praviao regarding sickness or death benefit which may be due to war operations. I declare
that I shall have no claim on the funds at the Society for any such illness or death.
Date the____________________day of___________________to
Signature of Candidate_______________________________________________________
(Christian (-) is full)
Proposed and Witnessed by________________________ Seconded by_______________
To Secretaries, state nature of evidence regarding applicant’s age_____________________
Signature of Secretary of Division____________________
(-) the all the perellminative have been properly carried ect)
MEDICAL CERTIFICATE
This is to certify that have I have carefully examined Mr_____________________________
of________________________________________________________________________
and find him in good health, free of organic disease and not suffering from any disability, either mentally or physically, which
would disqualify him from insurance in this Society.
Doctor’s Signature_____________________
Date__________________________________Address_____________________________
No. In Division_________________
Rase of Contribution_____________________________
(Including)
____________________________________________________________________
WORKERS’ CIRCLE FRIENDLY SOCIETY
REGISTERED NO. 1495 LONDON
FOR FRIENDLY SOCIETY AND EDUCATIONAL PURPOSE
DIVISION No_____________
FORM OF APPLICATION FOR MEMBERSHIP
Full name of candidate___________________________________________
(Black Capital Letters)
Full postal address____________________________________________________
(All questions must be answered in words)
Date of Admission______________________________
QUESTIONS
1. When were you born?
2. Give your age next birthday.
3. What is your employment?
4. State if married or single.
5. If married, how many children?
6. How many brothers have you?
7. How many sisters?
8. Are your parents living?
9. Are you is good state of health, and do you
ordinarily enjoy good health?
(s) give date and nature of last illness.
10. Is your wife in good health? If not, give
particulars of nature and duration of (-).
11. Has any Parent, Brothers or Sisters suffered
from fits, (-) or engagement of
mind? If to, give particulars.
12. Are you a member of any other Benefit Society?
If so, state particulars
13. Are you a member of a Trade Union?
14.Have you ever been a member of this Society?
If so, state number of Division.
15. Have you ever been refused admission to this
Society? If so, state reason for refusal.
16. Under which scale of Benefit do you wish to join?
17. In the event of your death, to when shall your
Death Benefit, if any, be paid.
CANDIDATES ANSWER
DAY MONTH YEAR
(-) : An (-) ever 29 years
of age (-) prodvice confidence of birth
or other (-) (-) of age)
Name_____________________________________________________________________Address__________________________________________________________________________________________________Relationship________________________________
DECLARATION TO BE MADE BY THE CANDIDATE
1, the undersigned, declare the aforesaid answer to be true. I agree that the same and this Declaration shall form the
basis of the Contract between myself and the WORKERS’ CIRCLE FRIENDLY SOCIETY ; i further declare that if admitted a
member of this Society, and as any time it should be found that the information given herein upon which I have been admitted
is (-), and that I have withheld anything, the knowledge or which would have presented my gaining admission to the Society,
the Society shall then he at liberty an canced my membership and that I shall forfeit all claims at the funds of the Society.
I also agree to be bound by all the rules of the society. As to benefits applicable to members joining the Society after the
31.12.44. I further agrees to your Praviao regarding sickness or death benefit which may be due to war operations. I declare
that I shall have no claim on the funds at the Society for any such illness or death.
Date the____________________day of___________________to
Signature of Candidate_______________________________________________________
(Christian (-) is full)
Proposed and Witnessed by________________________ Seconded by_______________
To Secretaries, state nature of evidence regarding applicant’s age_____________________
Signature of Secretary of Division____________________
(-) the all the perellminative have been properly carried ect)
MEDICAL CERTIFICATE
This is to certify that have I have carefully examined Mr_____________________________
of________________________________________________________________________
and find him in good health, free of organic disease and not suffering from any disability, either mentally or physically, which
would disqualify him from insurance in this Society.
Doctor’s Signature_____________________
Date__________________________________Address_____________________________
