Initial Request to become a beneficiary of the Thalidomide Trust

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In order to be able to resume this form later, please enter your email and choose a password.

Please provide the following information with as much detail as possible. 
Please note that by completing this form you are consenting to us holding this data and sharing it with external experts whose opinions are required to enable us to assess your eligibility to become a beneficiary of the Trust.  

A copy of our Privacy Statement for applicants is available upon request. 

Please note: 
You are able to save this form and resume the application later, before submitting it.  You will be asked to provide an email address and create a password when saving your form, which you will then use to access it again, so please ensure you make a note of it.  

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