APPLICATION FORM FOR MEMBERSHIP OF ICIP

Name (include title):

Job title:

Organisation:

Address:

Postal code:

Country:

Telephone (please include the country code):

Fax:

Email:

       Individual member

    Organisational member 

Please return this form to ICIP, c/o The Beth Johnson Foundation, Parkfield House, 64 Princes Road, Hartshill, Stoke-on-Trent, ST4 7JL, United Kingdom.   Telephone:  +44 1782 844 036  Email:  This e-mail address is being protected from spambots. You need JavaScript enabled to view it