Special Interest Group for Health Informatics

Membership Application Form

Please provide the following contact information:

*First name

*Last name

*Title

*Occupation

*Work Address

 
 
 

*Postal code

*Work Phone

Fax

*E-mail

*Home Address

 
 

*Postal code

*Home E-mail

Fax

*Home Phone

   

*Membership No.

   

*Employing Trust/Authority .

*Any Previous Relevant Experience.

*Special Interests Relevant to the Group.

   

*Are you prepared to be contacted for your opinion in relation to your experience and interests?

   

*Are you prepared to be read and comment on documents in relation to your experience and interests?

   

*Can this form be held on the Committee Representative home computer for use by the SIG for Information Management and the CPHVA?

*Date

Subscription fee £15 for year from October 2001

Please make cheques payable to: SIG for Information Management and post to:


Treasurer
6 Oxenhope
Bracknell
Berkshire
RG12 7DY

Tel: 01344 424 447

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