British
Ophthalmic Anaesthesia Society Member Registration Form
To The Branch
Manager
x…………………………………………………….
Postal Address
x…………………………………………………………………
……………………………………………………………………………………… |
STANDING
ORDER MANDATE
|
| |
Bank |
Branch Title (not
address) |
Sorting Code Number |
| Please Pay |
Midland Bank |
South Cleveland Hospital |
4 0 3 3 0 1 |
| |
Beneficiary's Name |
Account Number |
Quoting Reference |
| for the credit of |
British Ophthalmic Anaesthesia
Society |
2 1 8 4 4 6 3 6 |
|
| |
Amount |
Amount in words |
|
| the sum of |
£25.00 |
Twenty Five Pounds |
|
| |
Date
of first payment
|
|
Due
date and frequency
|
|
Date
of last payment
|
|
commencing
|
x |
and
thereafter every
|
YEARLY
|
until
further notice in writing or
|
|
and debit
my/our account accordingly
|
| PLEASE CANCEL ALL
PREVIOUS STANDING ORDER/ DIRECT DEBIT MANDATES IN
FAVOUR OF |
UNDER REFERENCE
NUMBER |
Account
to be debited |
Account
Number |
| |
|
x |
x |
Signature(s)
x………………………………………………… |
Date x……………… |
Personal details
Last name (Dr, Mr, Mrs, Miss, Ms)
First
name………………………………………………………………………………….…………………………
Department……………………………………………………………..Institution………….……………………
Address………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
City/County/………………………………………………Post
code…………………….…………………………
Phone………………………..Fax…………………………Email……………………………………………………
If you would like to become a member
of the British Ophthalmic Anaesthesia Society, please
print and complete the form for the bank standing order
where indicated by x with your personal details etc.
Completed form should be sent:-
Dr K-L Kong
Secretary, BOAS
Consultant Anaesthetist
City Hospital
Dudley Road
Birmingham
West Midlands
B18 7QH
|