Step 1 Tell Us About Your Organisation

Step 1 – Tell us about your organisation

Organisation name: ………………………………………………………………………………………….

…………………………………………………………………………………………………………………..

Address: ………………………………………………………………………………………………………

…………………………………………………………………………………………………………………..

……………………………………………………...Postcode: ……………………………..………………

Telephone: ……………………………………….Email: …………………………………………………

Website: ………………………………………………………………………………………………………

Directorate/Part of Organisation in which your post is located: ………………………………………...

Number of paid staff: / ...... / Total Number of volunteers: / …………
Number of youth volunteers
aged 20 yrs or under 
or
16- 24
(if not recorded as under 20yrs)
Please tick a box / …………

We need to supply statistics to the Department of Health so please consider your answers carefully so that we can make an accurate annual report:

Type of Organisation:
(please tick all that apply) / Areas Covered By Your Department:
(please tick all that apply)
Acute 
Ambulance Trust 
Foundation Trust 
Integrated Trust 
Mental Health Trust 
Other (please list) / Acute 
Elderly 
Hospice 
Primary Care 
Mental Health  / Learning disabilities 
Social Services 
Community 
Patient Transport 
Other (please list)

Step 2 – Tell us about the people at your organisation

Individual Membership: £65

Name of main person for NAVSM membership correspondence: ……………………………………..

Job title: ……………………………………………………………………………………………………….

Address: (if different from above) …………………………………………………………………………

…………………………………………………………………………………………………………………..

……………………………………………………...Postcode: ……………………………..………………

Telephone: ……………………………………….Email: …………………………………………………

Corporate Membership: £95 (1st 4 then £20 for each additional member)(Please continue on a separate sheet if necessary)

Name of person: ……………………………………………………………………………………………..

Job title: ……………………………………………………………………………………………………….

Address: (if different from above) …………………………………………………………………………

…………………………………………………………………………………………………………………..

……………………………………………………...Postcode: ……………………………..………………

Telephone: ……………………………………….Email: …………………………………………………

Name of person: ……………………………………………………………………………………………..

Job title: ……………………………………………………………………………………………………….

Address: (if different from above) …………………………………………………………………………

…………………………………………………………………………………………………………………..

……………………………………………………...Postcode: ……………………………..………………

Telephone: ……………………………………….Email: …………………………………………………

Step 3 – Please select your membership fee and method of payment.

(please tick)

Single £65 

Corporate £95 

Corporate Membership includes the first 4 members at £95; each additional member is £20 thereafter

Please provide the following details to your procurement/finance team:-

Company: NAVSMName: Claire Goldsmith

Position: Honorary TreasurerOur Reference: NAVSM MEM

Sort Code: 60-83-01 (NEW SORT CODE)`Account No: 20243287

Email:

Your Ref: Your company name. So we know where it is from

Cheque 

BACS 

Other 

Purchase Order Number …………………………………….

Step 4 – Final checklist

Have you included all contact details of members? : 
Have you included details of payment including name of Trust for our reference? : 

Step 5 – Additional information

We will use the contact details provided to send information relating to NAVSM membership and other services.

I give my consent for the details contained in this form to be processed in accordance with the Data Protection Act 1998 and understand that a list will be circulated to subscribing members only. Some data may also be published on the NAVSM web site for access by subscribing members only: 

We will contact the main person named for receiving NAVSM membership correspondence regarding certain formal and legal matters via email e.g. sending voting forms for our elections.

If you would prefer to receive this information by post, please tick here: 

Signed: ………………………………………………………………………………………………………..

Date: …………………………………………………………………………………………………………..

NAVSM membership application form
Complete and return this application form to
Joanna Rapson
Membership Secretary
Volunteering & Befriending Services
Nottinghamshire Healthcare NHS Trust
Duncan Macmillan House
Porchester Road
Nottingham
NG3 6AA / Any queries call 0800 052 1415

For NAVSM use only

Intro PackTo Treasurer

Webmaster advised Chair Advised Membership Number .