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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: 1 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: 2 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 3 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 4