NHS Confederation: Application form

Form fields marked like this * are mandatory.

How we will use your data

NHS Confederation will not pass any information onto third parties. I allow NHS Confederation to store and analyse this survey data and to use any results, including my data anonymously.

Please confirm your acceptance of this data use* I agree

Information on your organisation

Other (please indicate)

Name of your unit/centre/programme*

Name of your department/faculty/divisione.g Department of Health and Policy*

Organisation namee.g. London School of Hygiene and Tropical Medicine*

Address**TownPostcode

Telephone

Fax

Website URL

Please indicate the number of staff in your research unit. This includes ALL staff in the research unit e.g. secretarial, PhD fellows, IT etc. This will determine your membership fee.

Staff numbers and membership

Number of staff* less than 20 staff between 21 and 40 staff more than 41 staff.

Membership categories are as follows:

HSR organisation

less than 20 staff in research unit - £350
between 21-40 staff in research unit - £450
more than 41 staff in research unit - £550.

Existing NHS Confederation members

NHS organisations - Free of charge
affiliate members - Free of charge
commercial associates - See rates for HSR organisation.

Other types of organisations

By application - contact Stephan.groombridge@nhsconfed.org

Contact details

Name*

Address blockplease specify at least the first two lines of your addressAddress*TownPostcode

Email address*

Job title*

Contact details 2

Name

Address blockAddressTownPostcode

Email address

Job title

Contact details 3

Name

AddressAddress*TownPostcode

Email address

Job title

Declaration

I confirm that we wish to join the Health Services Research Network for a period of one year.

Name*

Date*

The NHSC may from time to time wish to share your information with other organisations.* . I'm happy for my information to be shared with organisations Please do not share myinformation with other organisations

The NHSC may from time to time wish to contact you with details of publications or events or with general information which we feel will be of interest to you.* Send me info on publications and events Do not send me info on publications and events