Membership Application Form & Bankers Order

I apply to become a member of The Guild of Catholic Doctors and send herewith a completed Banker's Order for the appropriate subscription (Full member £50; student member £10).

Full Name
Mailing address
Address (cont.)
City
Post code
Home Phone
E-mail

Enter your Specialty. Qualifications:

Medical Students - expected qualification date:   Preferred branch

Home Address (keep details visible in window)                                     Professional Address (or college address for students)

GUILD OF CATHOLIC DOCTORS BANKERS ORDER
Date:
To Messrs: (Your Bank Details)


Please pay forthwith to Lloyds bank Ltd, 190 Great Portland Street, London, W1
(Code No: 30-93-68) for the account of THE GUILD OF CATHOLIC DOCTORS
(Account no. 0081844) the sum of being my annual subscription for membership                                     and continue to pay this amount on 1st October annually until further notice, commencing and quoting my name and membership number on all transactions. This supersedes all previous orders to this body.

Signature..................................................................................  
Account number:.................................................................. Your Bank Sort Code .....................

Now please print this form and send it to:- Guild of Catholic Doctors, Hospital of St John and St Elizabeth, 60 Grove End Road, London, NW8 9NH.