[Application for membership of the BSCC]

Please complete all sections of this application form. Applications will be considered at the next meeting of the Council.

Membership details

Level of membership
Previous membership no.
Membership category

Personal details

Title
Forenames *
Surname *
Previous names
Birthdate
Sex

Contact details

Home

Address
City/Town
Postcode
Email

Work

Employer name
Department
Address
City/Town
Postcode
Telephone
Fax

Employment details

Please give details of your last three posts starting with your current role.

Employment 1

Post
Grade
Speciality
Hospital / Institution
Date of appointment

Employment 2

Post
Grade
Speciality
Hospital / Institution
Date of appointment

Employment 3

Post
Grade
Speciality
Hospital / Institution
Date of appointment

Qualifications

Qualification 1

Qualification
Date awarded
Awarding body

Qualification 2

Qualification
Date awarded
Awarding body

Qualification 3

Qualification
Date awarded
Awarding body

Registrant declaration

I, THE UNDERSIGNED APPLY FOR MEMBERSHIP OF THE BRITISH SOCIETY FOR CLINICAL CYTOLOGY AND DECLARE THAT THE FOREGOING STATEMENTS ARE CORRECT.

Name *
Date *

Proposer and seconder

All applications must be proposed and seconded by current members of the Society. Your application does not require signatures of the proposer and seconder, but they shall be contacted to vouch for your application.

Proposer

Name *
Membership number *

Seconder

Name *
Membership number *

Jonah Jones is a designer, programmer, film maker and photographer who specialises in the internet and usability. Jonah Jones