Membership Application & Renewal Form 2019
Please complete, sign and return this form to:
Secretariat: Janice Cooper, 3 The Oaklands, Broadmeadows, South Normanton, Alfreton, Derbys DE55 3BN. Or scan and email to: secretariat@eastmidlandslaterlifeforum.org.uk;
_________________________________________________________________________
Please complete all sections to ensure your correct listing on our database:
Agency/Organisation Name (if applicable):……………………………………………………………
Your name:…………………………………………… Job title/Position……………….………………
Email:……………………………………..…………………………………………….………………….
Tel:…………………………………........................... Mobile:………………………………………
All EMLLF correspondence will be forwarded via email to limit costs, if this is not possible please ensure we have your full postal address.
Address……………………………………………………………………………………………….….
………………………………………………………………………….Post Code…………………….
What type of Agency/Organisations are you? Please tick relevant box:
0 Voluntary organisation; Community Group; Charitable Company
0 Social Enterprise/Community Interest Company
0 Public/Statutory sector
0 Other – please specify i.e. individual………………….................................................
What type of membership are you applying for? Please tick relevant box:
0 Full membership with voting rights
Ex- Officio with full voting rights
0 Associate membership (non-voting)
0 Corresponding membership (non-voting)
I confirm that I/we uphold the ‘Aims & Objectives’ of EMLLF:
Signed: ……………………………………………………………………………. person detailed above
Signed: ………………………………………………..………Chair/Line Manager of above if applicable
Approved by EMLLF Executive Committee on: ………………………. Signed: …………...................
Janice Cooper, 14th May 2019