Age Anaesthesia Association APPLICATION FOR MEMBERSHIP

Please complete the forms below in BLOCK CAPITALS
and send to the Honorary Treasurer,
Dr Guy Turner


NAME. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Grade. . . . . . . . . . . . . . . . . . . . . . . .

ADDRESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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. . . . . . . . . . . . . . . . . . . . . . . . .POSTCODE. . . . . . . . . . . . . . . . . . . .
Hospital: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tel. no. Home:. . . . . . . . . . . . . . . . . . . . . . . Hospital. . . . . . . . . . . . . . . . . . . . . .

Fax no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Email: . . . . . . . . . . . . . . . . . . . . . . . .
Data on this form will be kept by the membership secretary on a computer database for purposes of membership management and the generation of mailing labels &c. Address details will not be given to outside bodies without permission. Bank details will not be disclosed to anyone.

INSTRUCTION TO YOUR BANK
TO PAY DIRECT DEBITS
Please complete name and full postal address of your bank
To the Manager:
……………. . . . . . . . . . . . . . . . .Bank /Building Society
(Address of member’s bank) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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. . . . . . . . . . . . . . . . . . . . . . . . . . . .Post code: . . . . . . . . . . . . . . . . .

1.Member’s name (in capitals please)
Surname Initials
2.Bank account details:
Name of Account holder
. Sort code Account Number
- -
Banks may refuse to accept instructions to pay direct debits from some types of account.
3. Your instructions to the bank, and signature.
- I instruct you to pay direct debits from my account at the request of AAGBI (Age Anaesthesia Association (AAA) )
- The amounts are variable and may be debited on various dates
- I understand that the AAGBI (Age Anaesthesia Association (AAA)) may change the amounts and dates only after giving me prior notice.
- I will inform the Bank in writing if I wish to cancel this Instruction.
- I understand that if any direct debit is paid which breaks the terms of this Instruction, the Bank will make a refund.


Signature Date