AMM MEMBERSHIP APPLICATION FORM by NikFozzar

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									       AMM MEMBERSHIP APPLICATION FORM
PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS.


YOUR FULL NAME
AND TITLE :

APPOINTMENT :



POSTAL ADDRESS



TELEPHONE No.


E-mail :


TYPE OF                      FULL MEMBERSHIP
MEMBERSHIP                   ASSOCIATE MEMBERSHIP (for trainees) *
REQUIRED (please tick) RETIREMENT MEMBERSHIP (for retired full members)
* Trainees in microbiology/virology are offered free membership until CCT date or 5 years
from application which ever is shorter.

PLEASE INDICATE YOUR METHOD OF PAYMENT BELOW:

ANNUAL SUBSCRIPTION                   PAYMENT BY                            PAYMENT BY
FEE                                 STANDING ORDER             ()            CHEQUE                ()
FULL                                     £40.00                                £50.00
RETIREMENT                               £25.00                                £30.00

PLEASE PAY BY STANDING ORDER! It saves you money and is easier for administration purposes.
Please inform us if the name on your bank account differs to your work title (e.g. if bank account in
maiden name or husband’s name).

SUBSCRIPTIONS ARE DUE ON 1st JANUARY EACH YEAR
Members who have not paid by the end of February will be removed from the membership list (after one
reminder!).

Payment by standing order:     Please send this form to the AMM Treasurer*. Complete the attached
                               standing order form and return it to your bank.
Payment by cheque:             Please enclose cheque payable to the “Association of Medical
                               Microbiologists” with this application form. Send them both to the
                               AMM Treasurer*.
*Dr Albert J Mifsud, Treasurer AMM, Department of Microbiology, Whipps Cross University Hospital,
Whipps Cross Road, Leytonstone, London E11 1NR
YOUR INSTRUCTION TO SET UP A NEW STANDING ORDER
FOR AMM SUBSCRIPTION* *revised 1999 (see details below)
ONCE COMPLETED PLEASE SUBMIT THIS INSTRUCTION TO YOUR BANK:

This instruction should replace any existing standing orders to AMM subscription.

1          Your details
     Your full name                                 Branch name and address




     Contact telephone no.                          Sort code                     Account number



     Account held in the name(s) of :



2          Standing order details
Does this instruction replace any                                  No       Yes 
existing standing order/other instructions?                                        If yes : please instruct your bank
                                                                                   to cancel any previous instructions
                                                                                   to the AMM below:
                                                                   Please cancel my previous instruction to
                                                                   the AMM (please tick box)
Pay to :
ASSOCIATION OF MEDICAL MICROBIOLOGISTS
Lloyds TSB
PO Box 2135              Account number                                       0    1     8     2     3    9     0
Marlow
SL7 3HG                  Sort code                                            3    0     9     4     2    8

Payment amount*
 £                                                                            (payment amount in words)

PLEASE MAKE AN IMMEDIATE PAYMENT THEN
Please pay on
 0    1     JANUARY ANNUALY                               Until this instruction is cancelled in writing

3          Instructions to bank
     I authorise you to debit my/our account, in accordance   Your signature(s)
      with the details in Section 2.
     This request is addressed to the bank which holds
      my/our account.
                                                               Date
*£40 per year - Full membership if paying by standing order
 £25 per year - Retired full members if paying by standing order

								
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