Home Full Membership Application Full Member application form Please complete the application form below to become a full member of Nagalro. Full membership includes insurance cover. Any queries please email us at nagalro@nagalro.com or telephone 01372 818504. Applicant DetailsQualificationsCurrent WorkWork ExperienceSpecific ExpertiseAdditional InformationDeclaration *First Name Middle Name *Surname Previous Names *Home Address Line 1 Home Address Line 2 *Town / City *County Postcode Home Phone *Business Phone *Mobile *Email *Ethnic OriginAsian - BangladeshiAsian - IndianAsian - PakistaniAsian - BritishAsian - otherBlack - AfricanBlack - CaribbeanBlack - BritishBlack - otherChineseChinese - BritishChinese - otherOf mixed parentageWhite - BritishWhite - EuropeanWhite - non-EuropeanWhite - otherPrefer not to stateOther *Social Care Council Registration Number Social Care Council Registration Expiry Social Care Regulatory BodySocial Work England (SWE)Social Care WalesScottish Social Services Council (SSSC)Northern Ireland Social Care Council (NISCC)Coru, Health and Social Care Professions Ireland Qualification Date Awarded Awarding Body Qualification Date Awarded Awarding Body Qualification Date Awarded Awarding Body Qualification Date Awarded Awarding Body *Employed by Local Authority or other statutory body Yes No *Employed by voluntary organisation or charity Yes No *Employed by Cafcass as Bank Worker, Practitioner or Manager Yes No *Employed by a social work agency or other independent organisation Yes No *Self-employed contractor to Local Authority or statutory body Yes No *Self-employed contractor to voluntary organisation or charity Yes No *Self-employed contractor to Cafcass Yes No *Self-employed contractor to social work agency or independent organisation Yes No *Self-employed - no regular contractual arrangements Yes No *Director, partner or manager of agency/organisation Yes No Employer/contractor From To Employer/contractor From To Employer/contractor From To Employer/contractor From To *Specific Expertise including languages spoken other than English and knowledge of specific culture: Do you wish to become a member of the Nagalro private members’ forum? This is an on-line group of members who exchange ideas and access information. *Join private members' forum Yes No *Have you been a Nagalro member in the past? Yes No What year were you a member of Nagalro? Do you wish to apply to join the Nagalro Directory of Independent social workers open to full members of Nagalro? There is an additional charge for this. *Join ISW Directory Yes No Are there any areas of training you would like Nagalro to focus on? Please detail. Please specify any areas of training Have you had a claim upheld (or is a claim currently outstanding) for professional negligence, unprofessional conduct or breach of confidentiality resulting in insurers having to pay damages? Yes / No If yes please give details Are you aware of any circumstances which may give rise to a claim being made against you, even though no such claim has actually been made to date? Yes / No If yes please give details Have you ever had a complaint made against you to your Social Work Registration Authority, please provide dates of the complaint and any hearings and also any interim or final outcome if appropriate. Yes / No If yes please give details *I have read and accept the criteria for membership Yes No *I have specified my social care registration number Yes No In those areas where registration with a regulatory body is not required in order to practice as a social worker please send the equivalent of a CRB check. *I have made payment (cheque or bank transfer) Yes No I have read the Nagalro privacy notice and consent to Nagalro processing my personal data in accordance with the terms of that notice. *Accept privacy policy Yes No *Signature *Date Cost of Membership Membership commencing from: October 2020 - 31 March 2021 £145.00 NB If you are paying from outside the UK banking system please contact the Nagalro office at nagalro@nagalro.com for a quote. Payment for the first year should be by bank electronic transfer to: Sort Code 30-94-77 Account No: 04223470 Name of Account: Nagalro OR by cheque made payable to Nagalro and sent by post. Please allow a minimum of 5 days for cheques to clear. After the first year, payment can be by annual or quarterly direct debit. Direct Debit forms will be sent to you with confirmation of your membership. Please note that payment must be for the full amount in GBS (£ sterling). For those members residing outside the UK, you may need the following information: BIC: LOYDGB21057. IBAN: GB62 LOYD 3094 7704 2234 70. We recommend that members from the Republic of Ireland send a bank draft as the banks charge high fees for bank transfers. Any queries please contact us at nagalro@nagalro.com or 01372 818504. 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