| Membership
Application Form |
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|
| Please
print out this page and send completed with your
cheque |
 |
All hospital locum doctors,
unemployed, NCCG and victimised doctors are eligible
for membership of this association. |
 |
TITLE |
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|
SURNAME |
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|
FIRST
NAMES |
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|
ADDRESS
FOR CORRESPONDENCE |
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|
EMAIL
ADDRESS |
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TELEPHONE
NO |
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|
FAX
NO |
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|
QUALIFICATIONS |
|
|
SPECIALITIES
IF ANY |
|
|
GRADES
OF POSTS HELD |
| HO |
|
SHO |
|
REG |
|
| SEN REG |
|
CONS |
|
ASSOC SP |
|
| STAFF GRADE |
|
| OTHER (specify)
|
|
|
|
GMC
REG NO |
|
|
FULL
/ LIMITED |
|
|
PLEASE
TICK YOUR SUBSCRIPTION TYPE |
| |
£20
to join and for a year |
|
| |
£25
for overseas subscription |
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| |
Free for
unemployed doctors or those who cannot work for
any reason
|
|
|
I HAVE
ENCLOSED A CHEQUE FOR THE AMOUNT SPECIFIED ABOVE
* UNLESS FREE
|
|
MADE PAYABLE TO "Locum
Doctors Association" |
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SIGNATURE |
|
|
DATE |
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| |
Please return to:
Locum Doctors Association, 8 Martine Close, Melling,
Merseyside. L31 1DJ. |
