Royal Academy of Medicine in Ireland by qng18193

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									           Royal Academy of Medicine in Ireland
    Frederick House                                                        Tel 01 633 4820
    2nd Floor,                                                             Fax 01 633 4918
    19 South Frederick Street,                                             www.rami.ie
    Dublin 2
    Email: secretary@rami.ie

                                  Nomination Form
Surname: ____________________________________________________________

Forename:____________________________________________________________

Registered Qualification: ________________________________________________

Date of Primary Qualification: ___________________________________________

Full Address of Candidate: _______________________________________________

_____________________________________________________________________

Tel No: ____________________________ Fax No: __________________________


Email: (PLEASE PRINT CLEARLY)_____________________________________

Appointments if any: ___________________________________________________

Section/s you are most interested in: _______________________________________

Please Note : Applicants for Student Membership are not required to fill in this section
                             This Section must be completed

    We hereby nominate the above as a candidate in all respects eligible to be elected to:

                      Fellowship (Senior Registrar Level or Equivalent)

                      Membership                           Associate Membership

Proposer _______________________Fellow          Seconder ______________________Fellow
           (Block Capitals)                             (Block Capitals)

Signature ________________________          Signature ___________________________

                Fees Effective From 1st January –December 31st 2009
     Annual Fee: Fellow EURO €185; Members EURO €95; Retired Fellows: €60
                          Student Membership EURO €20

								
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