Application for membership

Please print this page, complete this form and return to the Secretary: Professor A S Blinkhorn, University Dental Hospital, Higher Cambridge Street, Manchester M15 6FH, UK

I hereby apply for membership of the Institute of Health Promotion and Education as *Full/ Associate/ Corporate /Student Member (*delete as applicable), and agree to abide by the Constitution and Regulations and undertake to pay the Annual Subscription on the 1st January each year and in the event of my resignation I undertake to notify the Secretary in writing and return my Certificate by means of recorded delivery or registered post.

Surname PROF/Dr/Mr/Mrs/Miss/Ms

Forenames

Address

Postcode

Honours, awards, decorations:

Degrees or Membership of Professional Institutions:

 

Name and address of professional reference (required for Member and Fellow grades)

 

I am at present engaged in Health Promotion/Health Education in a *full/ part-time capacity (*delete as applicable).

Present appointment

Organisation

Special Health Promotion/Education interests:

 

I enclose initial Registration Fee and Annual Membership Subscription: Total£

Signed Date

For Official Use:
Date of Registration: Membership No: