IRH Membership, Joining Form

Date 7/1/2009

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How to join

Please print and complete this form, as appropriate:
or email Del Davies: delythd@rural-health.ac.uk with your details.

Name
Prefix:
Initials:
First name:
Last name:
Surname:

Home Address
House:
Street:
Town:
County:
Post/Zip Code:
Country:

Telephone:
Fax:
Email address:

Business Address
Name:
Street:
Town:
County:
PostCode:
Country:
Telephone:
Fax:
Email address:

Address to which correspondence should be sent (Please tick)	Home	Business

Occupation:

Qualifications:

Present employer:
Grade of membership applied for:

Signature:
Date:

For Student Membership
Course:
College:
Year of proposed graduation:

For Practice membership
Name of Practice:
Number of professional members:

For Corporate Membership
Name of organisation:

After completion please post to
Institute of Rural Health,
Gregynog Hall,
Tregynon,
Newtown, Powys,
SY16 3PW

The Institute will consider your application and may write to you asking for further information. Some of this information is necessary for registration and some will be used to construct a detailed database of members and their interests. The information contained in this form will not be published to anyone else without the person’s consent and is held under the terms of the Data Protection Act.

Please make cheques payable to The Institute of Rural Health.