The Membership Form
22.11.11
Dear Friend,
Thank you for deciding to become a Member.
Please type your details in the boxes provided and post this form to No. 6 Kingsland Avenue, Oakhill, Stoke On Trent, ST4 5LA, together with your £12.00 Membership Annual Fee, made payable
to the ICD Support Group.
Alternatively, you may submit this form below and post your Membership Fee
under separate cover.
All information supplied to the ICD Heart Support Group will remain in the
Strictest Confidence, as per the Patients Confidentiality Act.
Information held by the ICD Heart Support Group will only remain active, whilst
you remain a Member of the Group.
Should you decide to withdraw your Membership, please write to the above
address and request for your personal information to be destroyed.
