Country Membership

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Title*
First Name*
Last Name*
Customer Address*
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Postcode*
Customer Email*
Local Store*
Landline*
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Occupation*
	Your Interests... Farm & Smallholder Equine Pet & Bird Clothing & Footwear Hardware Home & Gift Outdoors Food & Drink
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	By ticking this box I/we hereby authorise and agree to opening a country membership account with Mole Avon Trading Ltd and agree to the terms & conditions stated at www.moleavon.co.uk/membership. Contact from Mole Avon Country Stores in the forms of Email, Text, Telephone & Mail. Yes