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APPLICATION FORM FOR MEMBERSHIP

I wish to apply for membership of the National Cochlear Implant Users Association for which I understand there is no charge at present.
I confirm that I am over the age of 18.

I give my consent for the Association to record my postal address details and my email address and for the Association to communicate with me by such means.  The Association will hold this information in a secure database which will be used solely for these purposes, and which will not be made available to any third parties.

The General Data Protection Regulation (GDPR) require that my explicit consent to store my contact details is so recorded

Title:                                     …………………………………………………………………..

First name or initial(s):         …………………………………………………………………..

Surname:                             …………………………………………………………………..

Full home address:              ………………………………………………………..

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Post Code:                          ……………..…………………………………………….

Email:                                 ………………………………………………………………..

Signed: …………………………………………………      Dated:  ……………………………………………

The Association has an annual subscription of £15, however trial membership is free to the end of the membership year in which you join.

Please print and post this application form to:

Treasurer,  NCIUA,  7, Eldridge Close, Dorchester, Dorset, DT1 2JS.