Membership Renewal Application Form

MEMBERSHIP RENEWAL APPLICATION

To renew your membership, please:

1. Fill in the form below (alternatively, click here to download a postal application form)

2. After submitting the form, please make your payment. Payment can be made either for 1 year or you can set up an annual auto renewal.

Contact Details

Surname(required)

First Name(required)

Email address(required)

Telephone(required)

Are you happy to appear on the ICO search for practitioners?(required)

Yes

Year of Passing the ICO foundation course

Main Clinic Address and Contact Details

Clinic Address Line 1

Clinic Address Line 2

County

Post Code

Clinic Phone 1

Clinic Phone 2

Clinic Email 1

Clinic Email 2

Clinic Website

Clinic 2 Address and Contact Details (if you have more than one clinic)

Clinic 2 Address Line 1

Clinic 2 Address Line 2

County

Postcode

Clinic 2 Phone 1

Clinic 2 Phone 2

Clinic 2 Email 1

Clinic 2 Email 2

Website

Clinic 3 Address and Contact Details (if you have more than two clinics)

Clinic 3 Address Line 1

Clinic 3 Address Line 2

County

Post Code

Clinic 3 Phone 1

Clinic 3 Phone 2

Clinic 3 Email 1

Clinic 3 Email 2

Clinic 3 Website

Correspondence details if different from clinic details

Address Line 1

Address Line 2

County

Postcode

Phone (Home)

Phone (Mobile)

Email address

Website

Are you practicing as an Osteopath?

Yes

If not please state what?

Are you human?(required)

This field should be left blank

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