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SCATA MEMBERSHIP APPLICATION FORM
Please provide the following details for the SCATA membership database. Type or write clearly.

TITLE AND INITIALS 

SURNAME 					FIRST NAME

POST HELD 

HOSPITAL (permanent staff)
or ROTATION and CCST DATE (trainees)

ADDRESS INCLUDING POSTCODE 

PREFERRED PHONE NUMBER FOR CONTACT 

PREFERRED EMAIL ADDRESS 

HOME PHONE NUMBER (optional)

MOBILE NUMBER (optional)

SECOND EMAIL ADDRESS (optional) 

PERSONAL WEBSITE URL (optional)

Email is SCATA’s preferred method of communication with members. SCATA will only use members’ email addresses for SCATA business and will not disclose them to any individuals or organisations outside SCATA. Members can choose if they wish to have their name and email address published in the Members Only area of SCATA’s web site for other members to see.

Do you want your name and email address to be published in the Members Only area of SCATA’s web site?		YES		 NO		(Delete as appropriate)

METHOD OF PAYMENT    Standing Order  /  Cheque  (Delete as appropriate)

The preferred method of payment is by Standing Order. A form for this is available separately. Cheques should be made payable to the Society for Computing and Technology in Anaesthesia. The annual subscription for permanent staff is £20, except for trainees or retired members it is £10

The completed form should be sent with your payment to the Honorary Treasurer of SCATA:
Dr Andrew Norton, The Barn, Cole Lane, Stickford, Boston, Lincolnshire, PE22 8EU
   
Telephone:  01205 480182   Email:  treasurer@scata.org.uk

www.scata.org.uk