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1. Member Registration Form 2. Payment

* indicates a required field.

Personal Details

Title	*		Required field
First Name	*		Required field Max. 40 characters
Last Name	*		Required field Max. 40 characters
Gender	*		Required field
Email	*		Must be unique. A valid e-mail address Required field
Date Of Birth	*		In dd/mm/yyyy format Required field
Mobile			Max. 255 characters

Work Details

Work Status		I am currently not employed	Check this checkbox if you don't have a work address
Qualification			Max. 40 characters
Job Title			Max. 60 characters
Department			Max. 255 characters
Organisation Name			Max. 60 characters
Work Address line 1			Max. 40 characters
Work Address line 2			Max. 40 characters
Work Address line 3			Max. 40 characters
Work Town			Max. 40 characters
Work County			Max. 40 characters
Work Country			Max. 60 characters
Work Postcode			Max. 60 characters
Work Telephone			Max. 255 characters
Work Fax			Max. 255 characters

Home Details

Home Address line 1	*		Max. 60 characters Required field
Home Address line 2			Max. 60 characters
Home Address line 3			Max. 60 characters
Home Town			Max. 60 characters
Home County			Max. 60 characters
Home Country			Max. 60 characters
Home Postcode	*		Max. 60 characters Required field
Home Telephone	*		Max. 255 characters Required field
Home Fax			Max. 255 characters

Other Details

GMC Number			If applicable
Prefered Mailing Address	*		Max. 255 characters Required field
Membership Type	*		Required field
Payment Method	*		Required field
Sponsor Name (your application must be sponsored by a member of the ICS)			Max. 255 characters
Sponsor Email			Max. 255 characters A valid e-mail address
Data Protection	*	Please confirm that you agree with our data protection policy	ICS' data protection T&C text

Marketing Section

I wish to opt in to receive the following			Please select each item which applies from the list
Reason For Joining			Please select your reason for joining The Intensive Care Society