BIA Membership Form

* Membership Type

Full Membership £100.00 for each year
Trainee Membership Free for one year
Retired Membership £10.00 for each year
Associate Membership Free for one year

Payment System

Online Direct Debit (GCP) Pay for BIA membership with our secure online Direct Debit form with GoCardless (*not applicable to membership categories that are free)

Title

Mr, Mrs, Miss, Dr, etc

* First & Last Name

Telephone

Mobile

* Your E-Mail Address

a confirmation email will be sent to you at this address

* Choose a Password

must be 6 or more characters

* Confirm Your Password

Present Appointment

Type of Post

Type of Post (Other)

Employer

Hospital/University/Organisation

Department

* Work Address 1

Work Address 2

* Work City

* Work Country

* Work County / Region / State

* Work Postcode

Mailing Address 1

Mailing Address 2

Mailing Address 3

Mailing County / Region / State

Mailing Country

Mailing Postcode

Main Specialty

Main Specialty (Other)

Professional Qualifications

* Expected Training Completion date (CCT or HSST end date)

(*Required Trainees Only)

Main Specialist Interest

Would you like to participate in representing the association in media consultations

Yes
No

Would you like to participate in Clinical Service Subcommittees at regional level

Yes
No

Would you like to be included on the BIA elist?

Yes
No

Exclude from Directory

if this box is checked, you will not be displayed in public members directory