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Affiliate Membership form

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




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  2. First name(*)
    Please enter your firstname
  3. Last name(*)
    Please enter your last name
  4. Email(*)
    Please enter a valid email address.
  5. Re-enter email(*)
    Please enter your email again
  6. Password
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  7. Organisation(*)
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  8. Job title
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  9. Address line 1(*)
    Please enter the first line of your address.
  10. Address line 2
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  11. Address line 3
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  12. Town(*)
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  13. County
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  14. Post Code(*)
    Please enter a valid postcode.
  15. Telephone
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  16. 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.
  17. 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:

  18. Name
  19. Address
  20. How did you hear about us?
    Please tell us where you heard about us.
  21. If other please specify:
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