Business Name*

First Name*

Last Name*

Position

Address (Line 1)*

Address (Line 2)

Town/City*

County*
AberdeenAlderneyAntrimArgyllArmaghAvonAyrBedfordshireBerkshireBerwickBlaenau GwentBridgendBristolBuckinghamshireButeCaerphillyCaithnessCambridgeshireCardiffCarlowCarmarthenshireCavanCentral LondonCeredigionCheshireClackmannanClareClwydConwyCorkCornwallCromartyCumbriaDenbighshireDerbyshireDevonDonegalDorsetDownDublinDumbartonDumfriesDurhamDyfedEast Riding of YorkshireEast SussexEdinburghElginEssexFermanaghFifeFlintshireForfarGalwayGloucestershireGreater LondonGreater ManchesterGuernseyGwentGwyneddHaddingtonHampshireHerefordshireHermHertfordshireInvernessIsle of AngleseyIsle of ArranIsle of BarraIsle of BenbeculaIsle of ButeIsle of CannaIsle of CollIsle of ColonsayIsle of CumbraeIsle of EiggIsle of GighaIsle of HarrisIsle of IonaIsle of JuraIsle of LewisIsle of ManIsle of MullIsle of North UistIsle of OrkneyIsle of RhumIsle of ScalpayIsle of ShetlandIsle of SkyeIsle of South UistIsle of TireeIsle of WightIsles of ScillyJerseyKentKerryKildareKilkennyKincardineKinrossKirkcudbrightLanarkLancashireLaoisLeicestershireLeitrimLimerickLincolnshireLinlithgowLondonLondonderryLongfordLothianLouthMayoMeathMerseysideMerthyr TydfilMid GlamorganMiddlesexMonaghanMonmouthshireNairnNeath Port TalbotNewportNorfolkNorth YorkshireNorthamptonshireNorthumberlandNottinghamshireOfflayOrkneyOxfordshirePeeblesPembrokeshirePerthPowysRenfrewRenfrewshireRhondda Cynon TaffRoscommonRossRoxburghSarkSelkirkShropshireSligoSomersetSouth YorkshireStaffordshireStirlingStrathclydeSuffolkSurreySutherlandSwanseaTipperaryTorfaenTyne & WearTyroneVale of GlamorganWarwickshireWaterfordWest GlamorganWest MidlandsWest SussexWest YorkshireWestmeathWexfordWicklowWigtownWiltshireWorcestershireWrexhamZetland

Postcode*

Telephone*

Fax

Email Address*

Website

Number of Employees

Business Description*

Level of membership required*
 Level 1 (5 employees or less): £120 pa Level 2 (6-20 employees): £240 pa Level 3 (21-50 employees): £360pa Level 4 (51+ employees): £480 pa Key sponsor: Contribution negotiable

Method of Payment*
 BACS Cheque
Payment monthly by standing order is available
 Please send a standing order mandate

Invoice should be made out to
(if different from other address):