2012 2013 250 Main Member Renewal form by 3WijU1Bi

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									     MEMBERSHIP APPLICATION FORM – 1st April 2012–31st March 2013

 Cost of membership                                                                 £250 first unit
                                                                                    (+ £50 per additional unit; see separate form)


 Please fill in a separate form for each unit


 Name of Organisation (Group)

 Name of Business/Home

 Postal Address




 Post Code



 Tel no.

 E-mail

 Website



 Owner's Name                                                                        Manager's Name

 Owner's Tel no.                                                                     Manager's Tel no.

 Owner's E-mail                                                                      Manager's E-mail



 Type of Provider: (please tick all relevant sections)                               Client Category: (please tick all relevant sections)

 Domiciliary                                                                         Older People

 Nursing                                                                             Mental Health

 Residential                                                                         Learning Disability

 Nursing + Residential                                                               Physical Disability

 Supported Living                                                                    Dementia

 Other (please specify)                                                              Other (please specify)

Please make cheques payable to Milton Keynes and Buckinghamshire Care Association
Please complete and return with the appropriate fee to:

MKB Care Association
Water Meadow House
Watermeadow
Chesham
Bucks, HP5 1LF

 Registered Office: Chandos House, School Lane, Buckingham, Bucks, MK18 1HD Registered in England and Wales Registered number: 6297440

								
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