European Pressure Ulcer Advisory Panel - Membership Application Form

EUROPEAN PRESSURE ULCER ADVISORY PANEL

Membership Application Form, 2007

Please print this page off and follow the instructions on it.

MISSION STATEMENT

The European Pressure Ulcer Advisory Panel's objective is to provide the relief of persons suffering from, or at risk of, pressure ulcers, in particular through research and the education of the public. The European Pressure Ulcer Advisory Panel is a registered charity, number 1066856.

MEMBERSHIP APPLICATION	PLEASE PRINT CLEARLY
Title (Prof, Dr, etc.):	___________________________________________________
First name:	___________________________________________________
Last name:	___________________________________________________
Degrees:	___________________________________________________
Full Postal Address:	___________________________________________________ ___________________________________________________ ___________________________________________________
Postcode:	___________________________________________________
Country:	___________________________________________________
Tel:	___________________________________________________
Fax:	___________________________________________________
E-mail:	___________________________________________________
Main fields of Interest:	___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

Membership fee:	£30 per year Which includes Certificate of Membership plus the EPUAP Review
Cheques should be made payable, in British Pounds drawn on a UK Bank, to:
	EPUAP Registered Charity 1066856
And application forms should be returned to:
	EPUAP Business Office 14 Aston Street, Oxford OX4 1EP United Kingdom Tel: +44-(0)1865 791725 Fax: +44-(0)1865 791725 Email EPUAP@aol.com
Arrangements can be made for payment by Access/Mastercard/Visa credit cards
	(There is a £2 service charge added for this facility)

a) Credit card type: Access/Mastercard/Visa (Please delete as appropriate) b) Amount to be debited: £32 c) Credit card number: ________________________________ d) Expiry date of credit card: ____ / ____ e) Exact name and initials on credit card: ____________________________________________________ f) Address to which credit card statements are sent: ___________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ g) Signature to authorise debit of annual subscription: _________________________________________

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