EPUAP Review 10.1.indd - European Pressure Ulcer Advisory Panel

epuap
E U R O P E A N P R E S S U R E U L C E R A D V I S O R Y PA N E L
Membership Application Form
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
Name: _________________ _______________________ __________________________ ______________________
Title (Prof, Dr, etc) First name Last Name Degrees
Full Postal Address: ___________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________ Postcode: ______________________
Tel: ___________________________________________________________
Country: ___________________________
Fax: _______________________________
E-mail: ______________________________________________________________________________________________
Main fields of interest: _________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Membership fee:
£30 per year (September – September)
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, UK
Fax: +44 (0)1865 791725
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: ____________________________________________________
Volume 10, Number 1, 2009 27