The Charles Herbert Aslin Society's On-Line Campaign Form

If you support the C.H.A.S's campaign, (The form of words is as follows: 'We, the undersigned, request Derby City Council to commit to part-funding a comprehensive memorial to the life and work of Charles Herbert Aslin, to be erected at a suitably prominent location, preferably in the precinct immediately in front of the 'Riverlights' development, in such a way that it is impossible for visitors to the complex to ignore its presence.'), please take a few minutes to fill in your details below. This enables us to determine the background and interests of our supporters and will be treated in the utmost confidence should this be requested. Thank you.

Surname

First Name/Names

Address

Name of company or voluntary organisation (if applicable)

Telephone Number (Home)

Telephone Number (Work)

Facsimile

E-Mail

WWW address (if applicable)

Age (optional)

Employment Status

Employed
(Please specify occupation)

Unemployed
Retired

Hobbies/Interests

If you have any comments on the issue which you would like the C.H.A.S. to forward on to the relevant authorities, please enter these below.

Please state whether or not you would like these comments passed on anonymously
Yes
No

If you answered yes to the above question, please state whether or not you would like these comments entered (anonymously) in the C.H.A.S.'s On-Line Comments Book
Yes
No

If you answered no to the question before last, please state whether or not you would like these comments entered in the C.H.A.S.'s On-Line Comments Book complete with your contact and personal details
Yes
No

Thank you for taking the time to complete this petition. If, having reviewed the contents of this form, you do not wish to fill it in please close this window to go back to the 'Site Map' from whence you came.

If you've come to this page directly, why not also visit the Charles Herbert Aslin Society's 'Site Map'?

If you've come to this page directly, why not also visit the "Mad Modernist's 'Site Map'"?

If you would like to take a look at comments sent in thus far to the On-Line Comments Book, click on the preceding link.

This form is a Copyright (2006) of Christopher Bentley: Founder of The Charles Herbert Aslin Society.