Request for WKPA & NKF Magazines

KMW and Kidney Life Data Base

All information below is protected under the Data Protection Act

The information obtained can only be used for the purposes specified. i.e. WKPA "Kidney Matter ... Wales" and NKF "Kidney Life"

( Please put my details on your database to recieve free of charge ( complete the information below and submit )

Q.1

Do you want to receive WKPA "Kidney Matters Wales" ? *

Q.2

Do you want to receive NKF "Kidney Life" ?

Q.3

Please give your title, first & last name

Title

First Name

Last Name

Q.4

Please enter your address below

House No./ Street

District

City

Post code

Q.5

Please enter your phone number below

Q.6

Please enter your date of birth below

MM
/

DD
/

YYYY

Q.7

Please enter your e.mail address below

(e.g. john@example.com)

Q.8

Please enter your catagory below

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