BPRS Membership form

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Please fill this membership form.On receipt of the form you will be sent bank details to set up an Annual Standing Order Mandate to BPRS with your bank .Your membership will be activated ONLY once the first payment is recieved.

Email *

Title (prof/Dr/Mr/Mrs/Miss/Ms/Other *

First name : *

Surname: *

Job title: *

Work address: *

Work post code: *

Telephone number: *

Home address: *

Home post code : *

Home telephone number : *

Category of membership applied for : *

Consultant grade

Non-consultant grade

Required

Email address : *

Please note that the preferred method of correspondence is via email.

From time to time we receive requests from third parties for contact information of BPRS members to promote conferences, meetings etc. Please indicate if you are happy for this information to be released at the discretion of the Convenor by ticking the appropriate box.

yes

Required

Send me a copy of my responses.

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