Online Membership Form

Company / Organisation Name

Department / Group

Address

Post Code

Contact Number

Email Address

Website

Description of Business Activity
Max 25 words:

1. Membership Rate (per year)
2. Associate - £175 + Vat
3. New start-up (first year of establishment) - £135 + Vat
4. 1 - 5 employees - £330 + Vat
5. 6 - 19 employees - £425 + Vat
6. 20 - 49 employees - £550 + Vat
7. 50 - 249 employees - £695 + Vat
8. 250+ employees - £835 + Vat

Main Contacts’ Details: (please provide the details for all of those in your organisation who would like to receive our e-newsletter and NHS InfoSource)

Important: You must add at least one contact. To do this, complete the four boxes below and click 'Add contact'. To remove a contact, select the name from the list and click 'Remove Selected Contact'.

First Name:

Last Name:

Job title:

Email:

Telephone: