Sectioii 1 Orgatiisation delails Proposed charity name ,, Qjrywock Youn CLob Secti()11 2 Po[%)I Il&il Dei411 Last naff Previous names Home address Avis CviM(K) (XJCL F(L(m, GIpJwnuir trJckbu Kla, I(HIE 3HV HomeTel no. Mobile no. Email Date of birth ,.otsbEIo3.. OcLupatK)n A you a trustee of any other charty? Yes No If yes, please provide detsils of the charity name(s) and charty number (s)
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