PLEASE COMPLETE IN BLOCK CAPITALS
Title Mr/Mrs/Ms/Miss/Other ______ Surname ________________________
Forenames ___________________________
Address______________________________________________________________________
Town _________________________ County _______________ Postcode _____________
Date of Birth _______________________ Home Tel _________________________
Mobile No ___________________________
I prefer not to be contacted by telephone YES / NO
Do you consider yourself to be disabled YES / NO
Employer________________________ Occupation ______________________
Part/Fulltime ________________ Department ______________________________
Works Address ________________________________________________________
Postcode _______________________
Employee Ref No __________________ National Insurance No ______________
Email address __________________________________________
Do you wish to receive the Unite Magazine YES / NO
You have the right t any time to stop us using your details for third party marketing purposes. If you do not wish us to communicate with you or share your contact for these purposesplease choose NO
If you are, or have been a member of a another trade union (including Amicus) you must complete the details below:-
Union _______________________ Branch [if known] _____________________
Membership No ___________________ Date of last payment _________________
Gender MALE / FEMALE
Ethnic Group [Please underline]
Asian or Asian Brit-Bangladesh Asian or Asian Brit- Indian Asian or Asian Brit-Other
Asian or Asian Brit-Pakistan Black or Black Brit-Caribbean Black or Black Brit-Other
Chinese Mixed-Other Mixed-White and Asian Mixed-White and Blk African
White-British White-Irish White-Other
I apply to become a member of the union. If accepted, I undertake to observe the Unite the union [Amicus section] rules.
Signature____________________
Date _________________
FOR BRANCH USE ONLY EMPLOYER REF ____________
PAYMENT VIA EMPLOYER CHECK-OFF