Want to Join?

TITLE/FIRST NAME:
SURNAME:
HOME ADDRESS:
POST CODE:
TELEPHONE (HOME):
TELEPHONE (WORK):
TELEPHONE (MOBILE):
E-MAIL ADDRESS:
DATE OF BIRTH: (Please note: We can only accept members over the age of 18 - this is a requirement of the hospital))	DAY: MONTH: YEAR:
OCCUPATION:
OTHER INTERESTS:
Please tell us why you want to join Hospital Radio Basingstoke and what you feel your membership would contribute to the station:
Have you any past experience within the radio industry (including student radio and other hospital radio stations?)
If you have answered "Yes", please give details:
Have you ever been convicted for involvement with an unauthorised (pirate) pirate radio station? Anyone who has been convicted of any offence for unauthorised broadcasting ('pirate' broadcasting) under the Wireless Telegraphy Act 1949 or Marine &c Broadcasting (Offences) Act 1967 or of an offence under section 97 of the Broadcasting Act 1990 cannot be involved (in any capacity at all) in the operation of the radio licence or the making of programmes included in the licensed service for five years after the date of conviction.
If you have answered "Yes", please give details:
Have you ever been involved in a charity organisation?
If you answered "yes", please give us details.
Please supply the names and addresses (including post code) of two people who have agreed to act as referees, one of which should be a current or previous employer (or department head at college). Neither should be an existing member of HRB or a relative. NOTE: We cannot take your application any further without the full names and contact details (postal address) of two referees. Both referees will be contacted during your provisional membership period.
NAME: ADDRESS: POST CODE:
Relationship to you:
NAME: ADDRESS: POST CODE:
Relationship to you:
Membership is renewed annually on January 1st and costs £20 a year. You will be asked for your membership before you start your training. If you join part-way through the year, this will be calculated on a pro-rata basis. Initial membership is provisional only and you do not have full membership/voting rights until you have been formally accepted as a full member of the station. An HRB polo shirt is £8. During the time of your provisional membership, we will follow up all references and all new members will be expected to complete and return a police check form. You will be given a membership pack of information and forms to complete when you are accepted as a member. Your training will start once these have been completed and processed. *You will be expected to do this within one month of being accepted as a member.* *By submitting this form, you agree to complete the CRB form and other membership paperwork within one month.* *You will also be asked to complete a form to apply for a parking permit in order to park at North Hants Hospital.* I authorise Hospital Radio Basingstoke to approach the above named referees for a personal reference on my behalf. By submitting the above, I declare that the information supplied is correct to the best of my knowledge and I agree that I will complete a police check form before I can be accepted as a full member of the station. By entering my name below, I am certifying that I have completed the form myself I have checked all of the information above. NAME: DATE:
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We will respond as soon as possible to let you know if we wish to take your application further.