Membership Application

Organisation Name:

Title:
Firstname:
Surname:

Address:
City:
Postcode:

Telephone:
Fax:
Email Address: The email address must be that of a named person ie not "enquiries" or "info" nor similar

Please select the option that most accurately describes your organisation's activities:	Claims Management Company Law firm (solicitor or chambers) Claims handler/manager (non legal) Medico-legal agency Rehabilitation/treatment provider Insurer Endowment/Financial Services Other

Membership Type	Full @ £500 pa Claims Regulation Authorisation Number: Associate @ £250 pa Note that firms registered with the Ministry of Justice are eligible for FULL membership only (and must state their CRM number on this form); non-registered firms are eligible for associate membership only

Payment Method	Please Invoice Pay monthly by Direct Debit

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