membership form

Text Box: The Scottish Society of Anaesthetists Membership Application Form Please return to: Dr Kerry Litchfield Department of Anaesthesia 2nd Floor, Walton Building Wishart Street Glasgow Royal Infirmary GLASGOW G4 OSF Tel: 0141 211 4620 Email: klitchfield@nhs.net

After your membership application is received and processed you will be put forward for membership at the following AGM. If you do not have a member to second you, one of the council members will oblige.

The membership fee is £20.00 per annum and is deducted on or around the 1^st January of each year.

Please complete the direct debit mandate attached.

SSA Home page

Name: _____________________________________	Grade: ______________________________________

Hospital Address	Home Address
__________________________________	___________________________________ ____________________________________________
__________________________________	__________________________________
__________________________________	__________________________________
__________________________________	__________________________________
Postcode: __________________________________	Postcode: ___________________________________
Telephone: ___________________________________	Telephone: ___________________________________
e-mail: __________________________________
Proposed by: _________________________________
Seconded by: _________________________________