The Pink Jukebox Trophy 2019 Membership Application

Names *

Partner 1 Name:	*
Partner 2 Name:	*

Preferred Method of Contact

Please be sure to provide contact details that correspond with your preferred method of contact. It is not necessary to provide other types of contact details. *

Email
Text Message

Telephone Call
Post (Mail)

Email Information

Contact Email 1:
Contact Email 2:

Telephone Information

Phone Number 1:
Phone Number 2:

Mailing Information

Street Address:
City:
Post Code:
Country:

Special Needs

Intended Competition Categories *

We intend to compete in the Women's Latin competition
We intend to compete in the Men's Latin competition
We intend to compete in the Men's Ballroom competition
We intend to compete in the Women's Ballroom competition

Anticipated classification (Starter, D, C, B or A) for each category:

Privacy consent *

We both consent to the publication of our names and country on the website and in the programme
We both consent to the publication of our names and country on the website but not in the programme
We both consent to the publication of our names and country in the programme but not on the website
We do not consent to the publication of our details

Country or countries represented
Please identify the country or countries that you are representing (for the programme and/or the website)

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