New Membership Application Form

Your details		Please complete for joint members
Title	-MrMrsMissDrMs	Title	-MrMrsMissDrMs
Forename		Forename
Surname		Surname
Address
Postcode
Telephone		Telephone
E-Mail		E-Mail
DOB	// dd/mm/yy	DOB	// dd/mm/yy

---

Do you have a physical disability that affects your mobility?	Yes	Do you have a physical disability that affects your mobility?	Yes
Do you use a motor vehicle or other mobility aid?	Yes	Do you use a motor vehicle or other mobility aid?	Yes
Do you have a Blue badge?	Yes	Do you have a Blue badge?	Yes

---

Subscriptions	£ enclosed
Full Members (with a physical disability that affects mobility)	£14.00 per annum
Associate Members	£14.00 per annum
Joint Members	£18.00 per annum
Life Members	£280.00
Donation (please help mobilise provide better service to members)
Mobilise Badges and Stickers
VAT is included in price shown. Please enter number required in the box and add the total cost to your payment.
Self-Cling windscreen badge (1 free to new members)	50p each
TOTAL ENCLOSED
Clicking print will open a new window showing the complete Membership Application Form. Print this, complete your payment details, sign and return to: Mobilise Organisation, National Headquarters, Ashwellthorpe, NORWICH, NR16 1EX. Please make cheques payable to "Mobilise Organisation"

PLEASE COMPLETE AND CLICK THE PRINT BUTTON BELOW

Full membership is given to people (drivers & non-drivers) with a disability which affects their mobility.
People with other disabilities and able-bodied people are welcome as associate members.
Joint membership is available for two people at the same address at a special rate.

---

---

You can also join mobilise by telephone, using you debit/credit card
CALL 01508 489449