Associate Membership Form ~ Co-operative Councils Innovation Network

Your Organisation

Council Name/Political Group/other Elected Authority*

Total Annual Budget (capital & revenue)*

Correspondence Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Facebook

Twitter

Lead Contact

Title*

First Name*

Last Name*

Job Title*

Mobile number*

Landline number*

Email address*

Enter Email Confirm Email

Your Leader/Mayor (if applicable)

Please check the box below to enter details for your leader/mayor

Enter details

Title*

First Name*

Last Name*

Job Title*

Mobile number*

Landline number*

Email address*

Enter Email Confirm Email

Twitter

Your Clerk/Chief Executive (if applicable)

Please check the box below to enter details for your clerk/chief executive

Enter details

Title

First Name

Last Name

Job Title

Mobile number

Landline number

Email address

Enter Email Confirm Email

Twitter

Your Officer Network representative (if applicable)

Please check the box below to enter details for your officer network representative

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Title*

First Name*

Last Name*

Job Title*

Mobile number*

Landline number*

Email address*

Enter Email Confirm Email

Your Comms/Marketing contact (if applicable)

Please check the box below to enter details for your comms/marketing contact

Enter details

Title*

First Name*

Last Name*

Job Title*

Mobile number*

Landline number*

Email address*

Enter Email Confirm Email

Your Invoicing contact

Title*

First Name*

Last Name*

Job Title*

Mobile number*

Landline number*

Email address*

Enter Email Confirm Email

Our Monthly eNewsletter

We’ll send our monthly eNewsletter to everyone already mentioned. Who else should receive our communications? (Max 10 email addresses per CCIN Member)

Add Recipents

Click the plus button to add further recipients*

Title	First Name	Last Name	Job Title	Telephone Number	Email Address