Application to become a Corporate Partner by 7o3NJoP


									                                                                             For Office Use:
                                                                             Application Number
Academy of Medical Educators
                                                                             Date received:
Application to become a Corporate Partner

A: Contact and organisation details (Please type or use block capitals)
      Address for

       Postcode:                                                            Country:
  Telephone no.:                                                                              Fax no.:
  Email address: (Primary)                                    (Secondary)

B: Declaration
The above-named organisation is committed to upholding and supporting the professional standards of the
Academy of Medical Educators.
I declare that the information provided on this form is accurate to the best of my knowledge.


 Print name:                                                     Date:

C: Information for prospective individual members sponsored by Corporate Partners

Examples of first year subscription rates for individual applicants sponsored by a Corporate Partner are
detailed below. Corporate Partners will be asked to confirm that they are sponsoring any membership
applications claiming the reduced rates.

                       Admission date            Discounted rate             Discounted rate
                                                 Associate above             Member above
                                                      £40k                         £40k
                        1 Oct–31 Dec                   Nil                          Nil
                        1 Jan–31 Mar                 £59.40                      £148.50
                        1 Apr–30 June                £44.55                      £111.38
                        1 July–30 Sept               £29.70                       £74.25

In future years (beginning on 01 January each year) members are required to pay the full year’s
subscription (£90 for Associates and £225 for Members). Council has agreed that subscription rates
should be frozen at these rates until 2013.

                  Academy of Medical Educators, Charles Darwin House, 12 Roger Street, London, WC1N 2JU
          Email: Charity no: 1128988 Company no: 5965178
D: Payment details

2011-12 Corporate Partnership subscription due:                               £ 500.00

Please indicate payment method:
    I enclose a cheque on a UK bank and made payable to Academy of Medical Educators
     Please use the credit/debit card details below:

Card no:                                                                           Security code:

Name on card:                                                  Expiry date:                  Start date:
Cardholder’s full address:

Cardholder’s signature                                                             Date
The Academy’s Green Policy works towards minimising our Carbon Foot print. If you require a receipt for
your application fee please indicate:
    I do not require a receipt              Please email me a receipt                    Please post me a receipt

     You may wish to consider setting up an annual or quarterly Standing Order for payment of your future
     annual subscription, which is a more convenient method for both you and the Academy. If you would
     like a Standing Order form sent to you, please tick the box.

E: Application process
Please return your completed application with the appropriate subscription fee to:
        Academy of Medical Educators
        Charles Darwin House
        12 Roger Street
        London WC1N 2JU.

We will normally confirm receipt of your application within four weeks. You will receive a welcome pack,
which will include more information about Corporate Partnership and special membership application forms
detailing the discounted rates for your organisation’s sponsored applicants.

Your application will be treated in strict confidence. Data provided on this form will be held and processed by
the Academy in accordance with its Data Protection Policy (available from
                                                                                                     28 September 2011

To top