SSM Logo

Online Membership Application
Note: This form has been tested using Internet Explorer 8 and Firefox 3
If you have technical difficulties, please inform the webmaster Charles Florey 

Please be sure to complete all the fields marked with an asterisk (*)
When you have completed the form, click the Submit button.

  

* I have read the constitution and agree to abide by the principles and bye-laws of the Society. (please tick the box)

Title:    First Name(s) *  Surname:*

Surname used for Bank account if different from above:  

What is your gender?           Date of Birth *
                                                                              Day/Month/Yr         (e.g. 23/09/56)

CONTACTS 
  Email:  *

  (Please complete at least one of your addresses below, but preferably both)

  Address at work:       

Department:

*
Institution:
Street:
(continued)
Town:
Post Code:
Country:
Tel:  

  Address at home:

Line1:

* 
Line 2:
Line 3:    
Postcode:
Country
Tel:     
Preferred address for mailing

 

 

 

 

 

 

 

  

 

Present Post:        *

Areas of Interest:
                       1: *
                       2:
                       3:

Proposer's name and address (up to 255 characters available):

                                  *

Proposer's email:   *

 

 Please tick this box if you do not wish any of your particulars on the Society's database to be disclosed to third parties (e.g. academic publishers; university or government departments wishing to identify people with a particular expertise).

  

Please remember to send in your cheque and standing order.