Change of Details Form

This update form is only for current members. If you wish to joint the BSPGHAN as an associate member please download the proposal form from the associate members page. Full and trainee members need to be proposed by a current member. The member can obtain a proposal form from the secretary at secretary@bspghan.org.uk .

Your details can be updated by downloading the Membership Registration Form and posting or emailing this back to our secretary or alternatively you can complete the online form below which will be automatically sent to our secretary:

» Download Membership Re-Registration Form 


Membership Details
Title :
First Name:
Middle Name:
Surname:
Previous Surname:
Preferred Name:
GMC Number (if applicable):
Primary Institutional Affiliation:
Secondary Institutional Affiliation:
Deanery (if applicable):
Employer:

if other* above:
Full Member Category
(Please select only one)







if other* above:
Full Member Terms
Associate Member Category





if other* above:
Associate Member Terms

Contact Details
Work Address (for correspondence):
Home Address:
Degrees/Diplomas (for correspondence):
Telephone (Work):
Telephone (Home):
Mobile number:
Fax Number:
E-mail Address:
I agree for the following information to be published, please tick: Work Telephone
Home Telephone
Mobile Telephone
Fax
E-mail

Special Interests
Clinical Activity:
Choose most appropriate description






Main Areas of Interest:
Please tick all that apply		 Clinical Practice
Patient Based Research
Laboratory Based Research
Epidemiology

Confidential Information
Date of Birth:
Sex:

Anticipated year of Retirement:
Name of Standing Account Holder:

 

Your details will be sent to Mrs Lloyd who manages secretarial services for BSPGHAN

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