Special Interest Group for Older People

Membership Application Form

Please provide the following contact information:

First name

Last name

Title

Occupation

Address

 
 
 

Postal code

Work Phone

Fax

E-mail

Home Address

 
 

Postal code

E-mail

Fax

Home Phone

   

Membership No.

   

Employing Trust/Authority .

Any Previous Relevant Experience.

Special Interests Relevant to the Group.

   

Are you prepared to be contacted for your opinion in relation to your experience and interests?

   

Are you prepared to be read and comment on documents in relation to your experience and interests?

   

Can this form be held on the Committee Representative home computer for use by the SIG for Old People and the CPHVA?

Date

Subscription fee is £10 for year from October 2001

Please make heques payable to: SIG for Older People and post to:


Lavender Cottage
West Porlock
Somerset
TA24 8NX
Tel: 01643 862845

 

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