Membership Application Form Fields marked with * are required Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Address* Street Address City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Telephone*Email* Enter Email Confirm Email Date of Birth DD MM YYYY How did you find out about UA?Membership Type*Full MembershipAssociate MembershipCompany MembershipCompany NameChoose your branch*BirminghamBrunel (Incorporating Bristol, Somerset & Wiltshire)CambridgeChurchillCotswoldsEast AngliaEssexLeicesterLondon South WestLothian & FifeManchester & NWNewcastle Upon TyneSheffield & DistrictShropshire, Wales and The MarchesSurreyYorkshire & HumbersidePostal BranchType of operation Ileal conduit/urostomy Bladder reconstruction/neo-bladder Continent diversion Other Type of operation (if other selected)Reason for operationHospitalConsultant surgeonAge at date of operationMembership Options*£14 per annumFree for 12 months (new members only)Would you like to add a donation?*YesNoDonation (£) Total £ 0.00 My application for membership of the Urostomy Association is made subject to the Memorandum and Articles of Association of the Urostomy Association (Company Registration No. 06918246) ('The Company'), to any rules for the time being made thereunder, and to any terms for membership applicable to the Company, and in the event of the Company being wound up while I am a member, or within one year afterwards, I undertake to contribute such amount as may be required, not exceeding the guaranteed sum of £1 for payment of the debts and liabilities of the Company contracted before ceasing to be a member, and of the costs, charges and expenses of winding up, and for the adjustment of the rights and contributories among themselves.Declaration* I agree that the annual accounts and Directors' report and Auditor's/Examiner's report on those accounts may be sent by electronic communication to the above email address (if any), published on the website of the Company at www.urostomyassociation.org.uk throughout the period of at least 14 days clear of the date of the meeting and notice of it instead of delivery or sending them by any other means. Here at the Urostomy Association we take your privacy seriously and will only use your personal information to support your membership and to provide the products and services you have requested from us. From time to time we would like to contact you with details of other products/ services relevant to your urinary diversion. If you wish to opt-out of us contacting you for this purpose please tick this box. Please note that any such information is sent from us, and your details would NOT be given to any third party. There may be instances where your contact details would be passed to a third-party (such as our printer for the purposes of sending our magazine), with whom we have a strict confidentiality agreement. If you wish to opt-out of this please tick this box. If you become a member of one of our local Branches, we would like to pass your details to the local Branch Secretary, who is a volunteer, so that they can send you details of meetings, newsletters etc. If you wish to opt out of this, please tick this box. Gift Aid declarationIf you are a UK taxpayer, we can reclaim tax on your subscription and any donations that you make. This is a valuable source of income to the Association as long as you continue to pay an amount of tax equal to the tax we reclaim on your donations and subscriptions. Please tick the box below which will enable us to do so. I wish the Urostomy Association to reclaim tax on this and any future subscriptions and donations until advised otherwise. Payment Method*Credit/Debit CardPayPalNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.