Name in Full:        Dr/Mrs/Ms/Miss

Permanent Address

Postcode                                                                  Tel No:

In the County of:

County of Birth:

Date of Birth

(if under 18 yrs):

Are you a member of any other County Golf Association?

Name all Golf Clubs in this County of which you are a member.

Home Club ­­­­­­_________________________________________entry date________

Other club(s) with entry dates

CONGU Handicap

(handicap limit 24)

Certified by

(Handicap Secretary)

Proposer and Seconder (must be a member of DALCGA)

Proposer: _________________________         Date __________________

Seconder _______________________             Date__________________