Application for Membership

Complete the online application form, or if you wish, download the application form at the bottom of the page and complete offline as per the instructions.

 

To the Membership Secretary, Plymouth Medical Society

Robert Jeffery, Orthopaedic Surgeon, level 11, Derriford Hospital, PLYMOUTH PL6 8DH.

 

 

I would like to apply for membership of Plymouth Medical Society. 

Categories of membership (please ring)                                                2018-19 subscription

Ordinary member        Qualified Medical Practitioners                                    £40                 

                                    Trainee doctors                                                             £5 (if paying by SO)

                                    Retired doctors (on application)                                  £20

Associate member      Non-medically qualified people                                    £40

                                    Trainee health professionals                                        £5 (if paying by SO)

                                    Medical, dental and health profession students           £5 (if paying by SO)

 

Please indicate your method(s) of payment.

·       I enclose a standing order, commencing on 1 October (preferred method).

·       I enclose a cheque payable to “Plymouth Medical Society” (£40 / £20).

The annual subscription is due on 1 October each year. The subscription for the current year is waived, if you send a standing order starting the following October.  The information on this form will be kept on the Society’s membership database. Only your name and dates and category of membership will be retained if you leave the Society.  No details will be given to third parties.

 

 

        PLYMOUTH MEDICAL SOCIETY

www.plymouthmedicalsociety1794.org

 

Standing Order

 

                                    BANK                           BRANCH          SORT CODE

Please pay                Lloyds Bank plc       Plymouth       30-96-68

 

                                    BENEFICIARY NAME                          ACCOUNT NO:

For the credit of:       Plymouth Medical Society              00543575

 

                                    AMOUNT (figures)                               AMOUNT (words)       

The sum of:              £                                                                                 pounds

on 1 October each year, until further notice

 

quoting the reference: ………………………………………(please enter SurnameFirstname)

 

This instruction cancels any previous order in favour of the beneficiary named above.

 

Name & address of your bank: (please print)

 

 

Your bank account no:…………………………..            Sort code:         -        -

 

Signature:                                                                             Date:                                                 

 

Please enter your details clearly in capital letters:

Title:               Forename(s):                                               Surname:

 

 

e-mail address:

 

 

Your home address:

 

 

 

Phone:

            

Please do NOT send this form directly to your bank. 

Please complete it and send it to: The Membership Secretary,

Robert Jeffery, Orthopaedic Surgeon, level 11, Derriford Hospital, PLYMOUTH PL6 8DH

 

 

Forename(s) *
Forename(s)
Are you willing to be sent information about Society events by e-mail? *
Are you willing to be sent information about the Society by post? *