Card Credit Uk Visa

							 CREDIT/DEBIT CARD PAYMENT SLIP


 Renewing member    □                 New member   □              Reinstating member     □
 Contact telephone number:
 Full name:                                                       GMC number:

 Member number (if known):                                        Card Type: Visa/MasterCard/Maestro
                                                                             Debit card/Credit card
 Card Number:   |__||__||__||__| |__||__||__||__| |__||__||__||__| |__||__||__||__| |__||__||__||__|

 Expiry Date:   |__||__| / |__||__|    Issue No: |__||__|

 Amount: £                                         Receipt Required? YES / NO

Please post to:                                                  Fax to: 020 7581 3648
Membership Support Department                                    Phone: 020 3188 7766
1 Bow Churchyard
London
EC4M 9DQ