Application Form

  


  Please see terms of membership.

download a printable version of this form

I wish to apply for membership only - £200.00
I am already a member of the British Association of Sclerotherapists and ...
I wish to attend the meeting on the 25th April, 2008 - £200.00
I wish to attend the dinner on the 24th April, 2008 - £60.00 more info
 
Member Application
Name    
Contact Address    
Telephone    
Mobile    
Fax    
Email    
 
Professional qualifications Registration number
Doctor GMC
Nurse NMC
Dentist BDA
Beauty therapist Other
Other    
Insured by:    
Address    
Ref.no    
 
Nature of practice
Full time NHS Hospital
Part time Private clinic
    Beauty salon
    GP Surgery
    Other
 
Sclerotherapy Training.
Name of trainer:    
Address    
Date    
Certificate Yes No    
  We will invoice you once the form has been processed.
     
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