Development PageMembership Application Form Before you complete this form, please note that you require a proposer and seconder both of whom must be Freemen of the Company of NursesIf you require any assistance with this please email enquiries@companyofnurses.co.ukTitle/RankFirst NamePreferred First NameLast NameDecorationsAddressAddress Line 1Address Line 2CityCountyPost CodeEmailHome PhoneMobileNursing Qualification(s)Nurse Training (date and place where completed)NMC Pin or equivalent (if no longer on the register, give previous NMC pin, UKCC or GNC Reg No)Date of BirthPlease state how you heard about the CompanyCurrent Role(Please tick those boxes which best describes your current role)Job Title / Leave blank if Retired and tick the Retired box below Acute Learning Disabilities Nurse Entrepreneur Post Grad Student Social Care Community Management Nurse Specialist Primary Care Student Nurse/Midwife Education Mental health Occupational Health Private Healthcare Health Visiting Midwifery Paediatrics Research Independent Military Nursing Residential Care RetiredWorking outside healthcare/nursing (please specify)Other (please specify)Previous Areas of SpecialityPlease tick those boxes which best describes your previous role/s Acute Learning Disabilities Nurse Entrepreneur Post Grad Student Social Care Community Management Nurse Specialist Primary Care Education Mental health Occupational Health Private Healthcare Health Visiting Midwifery Paediatrics Research Independent Military Nursing Residential CareWorking outside healthcare/nursing (please specify)Other (please specify)Preferred Professional Development AreasAccess RequirementsDo you have a disability or require reasonable adjustment when receiving Company communication or attending Company events Yes No Prefer not to sayPlease give further detailsOther Livery CompaniesAre you a Freeman or Liveryman of another Company ? Yes NoIf a Liveryman, please state your Mother CompanyHave you been granted the Freedom of the City of London ? Yes NoIf so, please give date of your admission to the Freedom of the City of London.Proposer and SeconderPlease note that your proposer and seconder must be Freemen of the Company of Nurses. Proposer First NameProposer Last NameSeconder First NameSeconder Last NameType of Membership(Please tick type of membership required)What type of membership are applying for? Annual Membership (£65 +£25 one off joining fee = £90 Apprentice (for Nursing Students Only)(£10)Annual Membership (£65 +£25 one off joining fee=£90)Apprentice (for Nursing Students Only)(£10)If you would like to make a donation, enter the amount hereTotal Payable (£)Please indicate below how you will make your payment BACS (preferred) ChequeTo: Lloyds BankSort Code: 30-92-92Account No: 3294 7968Account Name: The Company of NursesReference: Please use your surname and 2 initials eg. Smith E CI have paid by cheque made payable to: The Company of NursesPlease send the cheque to: The Honorary Clerk, The Company of Nurses, Apothecaries' Hall, Black Friars Lane, London, EC4V 6EJShould your application to become a Freeman of the Company of Nurses be successful, do you consent to us sharing your name, address and email with other Freemen on our Freeman only (Login) section of the web site for the purposes of creating local friendships and networks ? Yes NoI confirm that the information contained within this application form is accurate to the best of my knowledge and I give permission to the Company of Nurses to contact and communicate with me via email, telephone, text and post. I confirm that I have never been declared bankrupt and that I have no criminal convictions. I confirm that I have not been struck off the NMC register.I agree to inform the Company of any changes in my circumstances to clerk@companyofnurses.co.ukI give my explicit permission for the Company of Nurses to hold, process and share internally and with the City of London Corporation my personal data, as contained in this form.Please click Yes if you agree YesSubmit Form Monitoring InformationDo you have caring responsibilities? Please tick all that apply None Primary carer of a child or children (under 18 years) Primary carer of disabled child or children Primary carer of disabled adult (18 years and over) Primary carer of adult (18 years and over) Primary carer of older person or people (65 years and over)Checkbox Field Secondary CarerCheckbox Field OtherCheckbox Field Prefer not to sayEthnic GroupAsian or Asian BritishCheckbox Field BangladeshiCheckbox Field ChineseCheckbox Field Filipina / FilipinoCheckbox Field IndianCheckbox Field PakistaniCheckbox Field Any other Asian backgroundBlack, African, Caribbean or Black BritishCheckbox Field AfricanCheckbox Field CarribeanCheckbox Field Any other Black, African or Caribbean backgroundMixed or Multiple Ethnic GroupsCheckbox Field White & AsianCheckbox Field White & Black AfricanCheckbox Field White & Black CaribbeanCheckbox Field Any other mixed or multiple ethnic backgroundWhiteCheckbox Field British, English, Northern Irish, Scottish or WelshCheckbox Field IrishCheckbox Field Gypsy, Roma or TravellerCheckbox Field Any other White back groundOther Ethnic GroupCheckbox Field ArabCheckbox Field Any other ethnic groupCheckbox Field Prefer not to sayHow would you best describe your national identity? Tick all that apply.Checkbox Field BritishCheckbox Field EnglishCheckbox Field IrishCheckbox Field Northern IrishCheckbox Field ScottishCheckbox Field OtherCheckbox Field WelshCheckbox Field Prefer not to sayWhat is your gender ?Checkbox Field WomanCheckbox Field ManCheckbox Field OtherCheckbox Field Prefer not to sayDoes your gender identity match your sex as registered at birth (or within 6 weeks) ?Checkbox Field YesCheckbox Field NoCheckbox Field Prefer not to sayWhich of the following options best describes your sexual orientation ?Checkbox Field BisexualCheckbox Field Gay / LesbianCheckbox Field Heterosexual / StraightCheckbox Field OtherCheckbox Field Prefer not to sayWhat is your religion or belief ?Checkbox Field BuddhistCheckbox Field ChristianCheckbox Field HinduCheckbox Field JewishCheckbox Field MuslimCheckbox Field SikhOther religious beliefs Other (please specify)Checkbox Field No religionCheckbox Field Prefer not to sayPlease give more details on your other religious beliefsDisabilityThe Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial and long-term (i.e. has lasted or is expected to last at least 12 months) negative adverse effect on the person’s ability to carry out normal day to day activities.Do you consider yourself to have a disability according to the definition above ?Have a disability Yes No Prefer not to sayIf yes, please state the impairment which applies to youCheckbox Field Blind or sight lossCheckbox Field Deaf or hearing lossCheckbox Field MobilityCheckbox Field Manual dexterityCheckbox Field Learning DisabilityCheckbox Field Mental health concernCheckbox Field Speech impairment Checkbox Field Cognitive DisabilityCheckbox Field Other impairment e.g. epilepsy, cardiovascular conditions, asthma, cancer, facial disfigurement, sickle cell anaemia or progressive conditions such as motor neurone disease.Checkbox Field OtherCheckbox Field Prefer not to sayPlease press submit and thank you for completing the formSubmit Form
Scroll To Top