BRIGHTON AND SUSSEX MEDICO-CHIRURGICAL SOCIETY
THE AUDREY EMERTON EDUCATION CENTRE
ROYAL SUSSEX COUNTY HOSPITAL
EASTERN ROAD
BRIGHTON BN2 5BE

Tel: 01273 523346
www.brightonmedchi.org.uk
Email: cynthia.lewis@bsuh.nhs.uk

APPLICATION FORM:

NAME:.................................................................................................................................

QUALIFICATIONS:...............................................................................................................

DEPARTMENT or PRACTICE:.................................................................................................

RESIDENCE:........................................................................................................................

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TEL:..................................................................FAX:...........................................................

MOBILE:...........................................................EMAIL:.........................................................

hereby applies to be a member of this Society.

SIGNED:............................................................................................................(Applicant)

APPROVED:........................................................................................................(President)

DATE:.................................................................................................................................

SUBSCRIPTONS:

Claim as Gift Aid - yes / no
Paid by Standing Order: