General enquiry form

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Contact details

Can we update your personal details if any of the below information does not match the data we currently hold on your record? Yes No Full name: 绿帽换妻 membership number: Address: Best contact number: Where an onward referral is required, we will provide these contact details to another department in the 绿帽换妻. Do you give us your consent to pass on this information? Yes No Can we leave you a voicemail? Yes No Can we contact you on this matter by email? Yes No If we need to pass your enquiry to your local 绿帽换妻 office or a specialist 绿帽换妻 department, would you like any emails from them to be password protected? Yes No Email address you would like us to reply to Please confirm the email address you would like us to reply to Please list any times that you are unavailable for calls during the next week (9am-5pm): If you require any reasonable adjustments to help us assist with your enquiry, please let us know below. Please leave blank if not applicable

Employment details

Please write out in full, don't use acronyms.

Place of work Employer What date did you start working with your current employer? Ward or department Job category

Please confirm that you work under the supervision of a registered nurse, midwife or health visitor. If you do not, please call our 绿帽换妻 team on 0345 772 6100 as you may not be eligible for 绿帽换妻 membership.

Job title Band Weekly contracted hours Do you have any meetings scheduled? Yes No If yes, please give date, time and location: Are you already being supported by a rep? Yes No If yes, please include details below: Are you in the UK on a visa? Yes No If yes, please include details below (including how long you have been in the UK and when your visa expires):

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