| This
form can either be completed on the screen and then printed, or printed
and filled in by hand
(IN BLOCK CAPITALS). Please attach a Curriculum Vitae, stating
posts in SpR training and publications and it
MUST be signed by 2 Ordinary Members of the society and mailed to the
contact address. |
| Title |
|
Date of Birth
|
| Home Address |
preferred mailing address?
|
| Hospital Address |
preferred mailing address?
|
| NHS Region |
(region of employment if applicable) |
| Correspondance |
Please indicate address preferred for Correspondence:
Home/Hospital |
I
have a special interest in peripheral vascular disease and am regularly
engaged in the management of vascular patients: |
| Category |
Category of membership applied for - explanation here |
|
Opportunities may arise for The Vascular Society to share your contact details (name, hospital postal and e-mail address) with corporate sponsors or other third parties which we think may be of interest to you. If you have any objection to this please indicate YES in the box and we will amend our records
|
| We the undersigned,
as Ordinary Members of the Vascular Society of Great Britain and Ireland
testify that
________________________________________________________________________
who is known to us and is in every way a suitable candidate
for election.
Signed 1:____________________________________ Name
(capitals):__________________________
Signed 2:____________________________________ Name
(capitals):__________________________ |
Date Received:_____________________________
Approved:_______________________________ |
Membership - Join the Society - The Vascular Society Membership Application Form
