Application Form

Please fill out the application form below to become a member of the Liverpool Supporters Club of Durham Region.

 

Name:
Address:
City:
Province:	Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Prince Edward Island Quebec Saskatchewan Yukon
Postal Code:
Phone:
Cell:
Email:
How would you like to be contacted?	Phone Fax Email Snail Mail
Your Home Team:
Additional Information:

You can also print off the form below and bring it with you in person on any Liverpool game day to our club home which is located at the Courtyard Restaurant 1437 King St. E. in Courtice, Ontario.

OLSC Application Form