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Thursday, 15 May 2008

Print Page EPDA Membership Form

PLEASE COMPLETE AND SUBMIT THIS ONLINE FORM TO RENEW OR APPLY FOR EPDA MEMBERSHIP.

ALTERNATIVELY YOU MAY COMPLETE BY PRINTING THE FORM AND RETURNING THIS BY FAX OR POST TO THE ADDRESS AT THE BOTTOM OF THE PAGE.

Contact Details
* required information
(If not applicable, please add n/a in the required field)

 









 







Tulip Pins
Tulip Pin
As an EPDA member, each year, all organisations are entitled to receive up to 100 tulip pins free of charge to celebrate World PD Day.

Pins will be delivered to the above address unless directed otherwise. You will be invoiced for reimbursement of postage.

Do you require tulip pins?
YES / NO (Please delete)




Organisation Details
* required information


 




 


 

Does your organisation operate regionally?
YES / NO (Please delete)

 

 

Does your organisation operate nationally?
YES / NO (Please delete)

 

 

Do you have Support Groups / Branches?
YES / NO (Please delete)


 

Are you an existing member of the EPDA?
YES / NO (Please delete)




Board Members

 

 


 
Please include title (e.g. Mr, Mrs, Dr., etc.)

 



 
Please include title (e.g. Mr, Mrs, Dr., etc.)

 



 
Please include title (e.g. Mr, Mrs, Dr., etc.)

 



 
Please include title (e.g. Mr, Mrs, Dr., etc.)

 



Organisation Representatives
* required information

Main EPDA Contact Person
(preferably English speaking)


 
Please include title (e.g. Mr, Mrs, Dr., etc.)

 





Young EPDA PWP Contact


 
Please include title (e.g. Mr, Mrs, Dr., etc.)

 






Your Organisation's Nominated Medical Representative
(to work with the EPDA's Medical Advisory Board)


 
Please include title (e.g. Dr., Prof., etc.)

 













Please complete and send by fax or post to:

EPDA Contact details

Lizzie Graham, Secretary General
European Parkinson's Disease Association (EPDA)
4 Golding Road, Sevenoaks, Kent, TN13 3NJ. UK

Tel/Fax: +44 (0) 1732 457 683
email: lizzie@epda.eu.com