Download Membership Application Form - British Association of Dermatologists

BRITISH ASSOCIATION OF DERMATOLOGISTS
Please send completed forms with your CV to the Membership Administrator, 4 Fitzroy Square,
London, W1T 5HQ.
PERSONAL DETAILS
Surname:
Alt. Surname:
Forenames
Initials:
Title:
Nationality:
Date of Birth:
Specialty:
Sex: M
/F
CURRENT POST AND QUALIFICATIONS
Specialist Registrar
Associate Specialist
Foundation Year Doctor
Consultant
Specialty Doctor
Staff Grade
Professor
Medical Student
Other: Please specify
Qualifications:
Do you hold the MRCP qualification? Yes
GMC No:
/ No
Are you on the specialist register for dermatology? Yes
/ No
TYPE OF MEMBERSHIP APPLIED FOR:
Associate
Junior
Retired
Associate Trainee
Overseas
Trainee
Career Grade
Ordinary
Medical students – Please indicate expected year of qualification:
If Trainee, please give National Training Number:
Expected CCST:
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BRITISH ASSOCIATION OF DERMATOLOGISTS
CONTACT DETAILS - WORK
Main Work (Hospital)
Name:
Street:
Town / City:
Postcode:
Country:
Tel:
Fax:
E-mail Address:
Post Held:
Other Hospital:
Area:
Secretary: (Name)
Do you see private patients? Y
/N
Can you be contacted for private practice information? Y
/N
Private Practice
Name:
Street:
Town / City:
Postcode:
Country:
Tel:
Fax:
Medical School (for medical students only)
Name:
Street:
Town / City:
Postcode:
Country:
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BRITISH ASSOCIATION OF DERMATOLOGISTS
CONTACT DETAILS - HOME
Home
Name:
Street:
Town / City:
Postcode:
Country:
Tel:
Fax:
Mobile:
Where would you like your correspondence to be sent?
Work
Private Practice
Home
SPECIAL INTEREST GROUPS
Are you a member of any of the following Special Interest Groups?
The British Society of Cutaneous Allergy
British Cosmetic Dermatology Group
British Epidermo-Epidemiology Society
British Photodermatology Group
British Society for Dermatopathology
British Society for Dermatological Surgery
British Society for Investigative Dermatology
British Society for Paediatric Dermatology
British Society for the Study of Vulval Disease
The Senior Skin Group
The British Teledermatology Society
UK Dermatology Clinical Trials Network
British Society for Skin Care in Immunocompromised Individuals
Psychodermatology UK
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BRITISH ASSOCIATION OF DERMATOLOGISTS
SIGNATURES
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:
IMPORTANT INFORMATION:
Medical students applying for Junior membership will require a single signature from an Ordinary or
Honorary member of the BAD confirming that they are undertaking a medical degree at the university specified
on this form
Overseas nominations must be supported by written citations from two Ordinary or Honorary Members.
Please note that Associate, Career Grade, Trainee and Retired Members cannot propose or second
Applications for Membership
From time to time we may co-operate with other organisations to send you information about issues
relating to dermatology. If you do not wish to receive this information please tick the box
Please remember to enclose a photograph
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