BIPA membership form 2020 (3)
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BIPA MEMBERSHIP FORM 2020

Surname: Dr/Prof . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

First name (Given name) . . . . . . . . . . .  . . . . . . . . . . . . . . . .  .. . . . . . . .  .. . . . . .  . . . .

Mailing Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . .  . . . . . . . . . ..  .. .  . . ..

Email: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tel No: . . . . . . . . . . . . . . . . . . . . .        Mobile:  . . . . . . . . . . .  . . . . . . . . . . . . .

Grade/Post: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .

University of Graduation: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Year of Graduation: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

GMC Registration Number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Area of Speciality: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I wish to become a (tick the one applicable) – see the details at www.bipa.org.uk 

 Life Member                                                Annual Member £50  

     £200 One off                                                          £50.00 yearly                

We are pleased to offer on-line BIPA membership payment by BACS.

BIPA A/C No: 46629149

Sort code: 60-01-19

I agree to uphold the aims and objectives of BIPA and would not do anything that would bring disrepute to BIPA.

Signature & Date

Please send the completed form to:

Dr Ananta Dave, President of BIPA by email: enquiries@bipa.org.uk

For updated information please consult BIPA website www.bipa.org.uk

Please inform us any change in your contact information ASAP.