INMO MemberShip

IMPORTANT: PLEASE PRINT YOUR DETAILS IN ALL FIELDS IN BLOCK CAPITALS

** You will find your INMO number on the postage label of WIN magazine!

**INMO Membership Number: *

Name (First Name): *

Surname: *

Date of Birth: *

Home Address: *

Work Location Address: *

Study Address:

If you are a PHN or Community RGN

Name of Community Care Area:

Name of Local Health Office:

Employment Grade * (e.g. CNM1 etc):

INMO Section: *

INMO Branch: *

Student: (Please tick appropriate)

YesNo

Telephone (Landline) Home:

Work:

Mobile Phone

Home:

Work:

Please note this mobile number will only be used by INMO for important updates and will not be given to any other party at any time. If you have any queries, please call membership department: 01 6640600

Email Address (Please Print Below)

Personal: *

Work:

I Agree - THE ABOVE DETAILS ARE CORRECT AS OF DATE: 10/03/2010