Membership Application

Name

Title

Date of Birth

Qualifications

Date completed CCST

GMC Reg No

Address for correspondence

Private Hospital/s Address

Name of secretary

Telephone number

Fax number

E-mail Address

Mobile No (for our records only)

I would like to join UKAAPS and agree to pay £350 for new membership and £150 renewal every year thereafter. Please tick
I agree to send a cheque. Please make cheques out to UKAAPS and send to. The Lavenham Clinic, 3 High Street, Lavenham, Suffolk CO10 9PX

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