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 __________________________________________  

You have the right at any time to stop us using your
details for third party marketing purposes.
       

Do you wish to receive the Unite Magazine   YES / 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----------------------------------------      

PAYMENT VIA EMPLOYER CHECK-OFF

EMPLOYER REF ____________