Membership Application Form 1^st January – 31^st December 2010

Please complete the form below with your subscription of

 £10.00 by cheque made payable to RCN OHNG-SW and return to:Siân Edwards (membership secretary), 12 Kingswall Malmesbury Wiltshire SN16 9BJ.

Cheques should be made payable to RCN SW OHNG. Receipt will only be provided if S.A.E. is enclosed.

Date: _____________________________ RCN No: __________________________

Full name: __________________________________________________________________

Mailing Address:_________________________________________________________________

_______________________________________Post Code: _________________

E-mail address:__________________________________________________________

To reduce cost correspondence will only be sent by post if specifically requested.    

Telephone (home): ________________________ Telephone (work): ______________

Place of Work __________________________ Job Title:________________________

Nature of business/employment: ___________________________________________

Qualification (circle those applicable): RGN/OH Certificate/Diploma/Degree/Other

Please give further details____________________________________________

Would you be interested in volunteering to help or join the committee? Yes/No

Would you be interested in offering clinical support to a colleague?   Yes/No

Do you want to be included in a membership directory for distribution to the group for networking purposes?   Yes/No

Please circle your preferred area for study days: Cornwall/Plymouth/Exeter/Taunton/Other

Please give details:__________________________________________________

Data Protection Act Please note that by submitting this form you are granting us your permission to hold a record of your details. This data will be used for the sole purpose of the RCN OHNG-SW and it will not be shared with any other organisation.