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)