>> Biographical Details

Each member is requested to provide the following biographical details, which will be of help to future biographers when preparing entries for our own 'Munk's Roll'.  They will be regarded as confidential.

Please enclose a passport size photograph clearly marking on the reverse your name and date.

Members will appreciate the importance of updating the information from time to time.

Please Complete in BLOCK CAPITALS

Surname:                                         Forenames (or other names):                         

Date of birth:                                     Place of Birth:                                         

Nationality:                                                                                                   

Civil Honours, titles and dates:                                                                         

Full names of Father:                                                                                      

Occupation of Father:                                                                                     

Full names of Mother:                                                                                     

Occupation of Mother:                                                                                   

If married, year of marriage:                                                                             

Full names of wife / husband:                                                                           

Occupation of wife / husband:                                                                          

Children's Name                          Sex                                  Date of Birth

Any family relationship to other physicians or dermatologists living or dead.

Any other family or historical connection with medicine or dermatology.

Education

Schools:                                                                                                       

University and / or College:                                                                              

Undergraduate hospital / medical school:                                                            

Degrees and diplomas with dates, honours and distinction:                                    

Appointments held, with dates:

Junior:                                                                                                         

Senior:                                                                                                        

Non Medical appointments (including armed forces) with dates:

Principal publications, with dates:

Hobbies, sporting distinctions and other interests:

Signed:                                                                 Date:                                     

Address:                                                                                                      

Reminder: Please Enclose a Photograph