APPLICATION FORM

Please complete the form below to apply for Affiliation to the James Lind Alliance. (completing the Affiliate application form automatically adds your details to the mailing list).

>> Edit your entry <<

*(Compulsory Field)

Prefix
*First Name
*Last Name
Job Title
Organisation
*Address1
Address2
Address3
*City
County
*Post Code
*Country
Tel Home
Tel Work
Tel Mobile
Fax
*Email Address
*Verify Email Address
*Please tick which information you would like to receive	Email Post Both
*Please tick which information you would like to receive
Applicants for Affiliation to the James Lind Alliance should provide the following details:
Are you applying for affiliation as an individual or an organisation - please tick appropriate box	Individual Organisation
*Which of the following best describes you (if Other chosen please add description in box below)	Other:
*A brief statement of background and reasons for interest in the James Lind Alliance
*A brief indication of how you can contribute to the objectives of the James Lind Alliance
We would like to list you or your organisation as an Affiliate on our website, drawing attention to your website if you have one. Please tick the appropriate box	Yes No Website (Please do not add http://)
*Please enter a password (This will enable you to edit your details should they change in the future)

If you encountered any problems while completing this form please email patkinson@lindalliance.org

Users join our mailing list voluntarily when signing up through a form on our website or by email. The information you provide will only be used to provide you with information on the work of the James Lind Alliance or other relevant information. It will not be disclosed to a third party without your permission. If at any time you would like your details to be removed from the mailing list please contact us by email: patkinson@lindalliance.org

For further information please contact Patricia Atkinson patkinson@lindalliance.org

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APPLICATION FORM