Application Form Fields marked with * are required Name* Mr.Mrs.MissMs.Dr.Prof.Rev. 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Type of operation Ileal conduit/urostomy Bladder reconstruction/neo-bladder Continent diversion Not applicable Other Type of operation (if other selected) Reason for operation Hospital Membership Options* UK Membership - free for 12 months, £16 per annum thereafter Overseas Membership - £32 per annum Would you like to add a donation?* Yes No Donation (£) Gift Aid declarationIf you are a UK taxpayer, we can reclaim tax on 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. 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 donations until advised otherwise. 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.devurostomy.wpengine.com 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. By completing this form, you are confirming that you are consenting to the Urostomy Association holding and processing your personal data strictly in accordance with our Data Privacy Notice.Payment Method* Credit/Debit Card PayPal Credit/Debit Card Details*Card Details Cardholder Name EmailThis field is for validation purposes and should be left unchanged.