Organisation Affiliate Sign Up

1. Personal Details

Gender MaleFemaleOther

First name:

Surname:

Organisation (if applicable):

Address:

Street:

Town:

County:

Postal code:

Make my address public:Make my address Hidden:

2. Contact Details

Mobile:

Phone/Landline:

Company:

Website:

Email:

Create Password:(Please include one or more upper and lower case letters, numbers, and marks)

Confirm Password:

Corporate Code (optional):

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4. Summary

Terms and Conditions:

I have read and agree to abide by the MII Code of Ethics and Practice I have read and agree to abide by the MII Code of Ethics and Practice I agree to be bound by the MII Complaints and Disciplinary Procedure I agree to be bound by the MII Complaints and Disciplinary Procedure I have appropriate insurance in place for my mediation practice (if applicable) I have appropriate insurance in place for my mediation practice

Not yet insured - comment on reason why:

Payment Offline:Online with Paypal, Debit or Credit Card:

Organisation Affiliate Form

To complete this application form you will require the following information: