Application Form

The National Cochlear Implant Users Association

Application for Membership

I wish to be registered as a Personal/Corporate/Affiliated member of the Association and enclose a cheque or postal order for the annual subscription of £.........

I confirm that I am over the age of 18.

I confirm that I wish NCIUA to reclaim tax via Gift Aid.

(Please delete if you are not a UK tax payer, or do not wish the Association to reclaim tax via Gift Aid)

[Signed] .................................

[Date] .................................

Name( in Capitals) .............................................................................

Address .............................................................................

............................................................................

Post Code ...............................

Telephone No ...............................

Fax No ...............................

Email Address ............................................................

Regional Sub Group Member of ..............................................

Please return this completed form together with your cheque or PO , made payable to 'NCIUA', to;

Treasurer
NCIUA
7 Eldridge Close
Dorchester
Dorset
DT1 2JS

Annual subscriptions are free until the March following joining. Thereafter an annual subscription of £10 for Personal members is recommended.
Corporate Membership is offered at £25 per year.
Local CI support groups are also invited to become NCIUA affiliated members for which a donation is requested.

If you have any queries, please e-mail us at enquiries@nciua.org.uk