BAPS MEMBERSHIP APPLICATION FORM
Please first select the Membership type for which you are applying:
Membership type
Ordinary
Overseas
UK Associate
Overseas Associate
First Name
Last Name
Date of Birth
Sex
Male
Female
Title
Mr
Miss
Mrs
Ms
Dr
Prof
Degrees and Diplomas with dates
Present hospital post
Hospital/Institute
Address
Address
Address
Town/City
Postal Code
Country
Telephone number
Fax number
Email address
Do you hold ultimate responsibility for patients?
Yes
No
Is your practice solely confined to children?
Yes
No
If not, what proportion of your time is occupied looking after ADULTS?
%
How long have you held your present position?
Months/Years
If you are applying for Associate Membership,
is your current appointment a training post in paediatric surgery?
N/A
Yes
No
State any other Paediatric Surgical Associations
of which you are a member
Please provide the name and address of a paediatric surgeon who is a member of BAPS who is prepared to support your application:
(for UK applicants this should be a UK surgeon. For overseas applicants this should be a surgeon in your own country)
