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Affiliate Membership form

  1. Please select the following rate that applies to your organisation(*)









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  2.  
  1. First name(*)
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  2. Last name(*)
    Please enter your last name
  3. Email(*)
    Please enter a valid email address.
  4. Re-enter email(*)
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  5. Organisation(*)
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  6. Job title
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  7. Address line 1(*)
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  8. Address line 2
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  9. Address line 3
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  10. Town(*)
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  11. County
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  12. Post Code(*)
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  13. Telephone
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  14. How many carers do you reach with your support and services?(*)
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    Please give an estimate of the number of carers you provide information, support or services to each year.
  15.  
  1. Alternate invoice details

    We will send you a copy of the invoice to the details provided on the previous page.

    If you need to send the invoice to someone other than yourself please add their details here:

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  3. Email
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  4. Address
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  1. How did you hear about us?
    Please tell us where you heard about us.
  2. If other please specify:
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