>> Application Form

BRITISH ASSOCIATION OF DERMATOLOGISTS

Please send completed forms with your CV to the Membership Administrator, 4 Fitzroy Square, London, W1T 5HQ.

Please use BLOCK CAPITALS

Surname:                                         Alt. Surname:                                       

Forenames:                                                    Initials:                                  

Title:                                                              Nationality:                           

Date of Birth:                                                   Specialty:                             

From:  (date)                                                                                            

Qualifications:                                                                                            

Sex:     M / F             GMC No:                                       Accredited:  Y / N

Type of Membership applied for: (Please tick)

Trainee  
Ordinary   
Retired
Overseas*     
Associate Trainee
Associate Member

If trainee please indicate
National Training Number:                                Expected CCST:                      

Main Work (Hospital) Name:                                                                  

Street:                                                                                                     

Town / City:                                                                                              

Postcode:                                             Country:                                         

Tel:                                                    Fax:                                               

Post Held:                                                                                                 

Regional Health Authority:                                                                            

Other Hospital:                                      Area:                                             

Secretary: (Name)                                                                                      

E-mail Address:                                                                                          

Do you see private patients?       Yes / No

Can you be contacted for private practice information?   Yes / No

Private Practice Name:                                                                          

Street:                                                                                                     

Town / City:                                                                                              

Postcode:                                             Country:                                         

Tel:                                                    Fax:                                               

Home Name:                                                                                             

Street:                                                                                                     

Town / City:                                                                                              

Postcode:                                             Country:                                         

Tel:                                                     Fax:                                               

Would you like mailings sent to your work, or home address?   (Please circle)
Work / Private Practice / Home

Are you a member of any of the following Special Interest Groups:

British Contact Dermatitis Society (BCDS)     Yes / No
British Photodermatology Group (BPG)      Yes / No
British Society for Dermatopathology (BSD)     Yes / No
British Society for Dermatological Surgery (BSDS)    Yes / No
British Society for Investigative Dermatology  (BSID)    Yes / No
British Society for Paediatric Dermatology (BSPD)    Yes / No
British Epidermo-Epidemiology Society (BEES)     Yes / No

I hereby agree to abide by the Constitution of the British Association of Dermatologists.

Signature:                                                  Date:                                          

We the undersigned, Ordinary / Honorary members of the British Association of Dermatologists, testify that the above named, who is personally known to us, is in every way a suitable candidate for election.

Proposer                                                 Seconder

Name:                                                           Name:                                                 

Signed:                                              Signed:                                               

Date:                                                 Date:                                                 

Please Note that Trainee and Retired Members Cannot Propose or Second Applications for Membership 

* Overseas nominations must be supported by citations from two Ordinary or Honorary Members.