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Individual member Application Form
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APPLICATION FOR MEMBERSHIP OF INSTITUTE OF REMOTE HEALTHCARE

Please complete the form below to enable the IRHC Membership Committee to assess your application and appropriate grade of membership

NAME

ADDRESS

TELEPHONE

E MAIL ADDRESS

DATE OF BIRTH

CURRENT POST

NAME & ADDRESS OF CURRENT EMPLOYER

(Please confirm that this contact can be deemed a referee for the purposes of membership eligibly. If not please provide alternative referee)

NAME AND ADDRESS OF PREVIOUS EMPLOYER

(Please confirm that this contact can be deemed a referee for the purposes of membership eligibly. If not please provide alternative referee)

TIME WITH CURRENT EMPLOYER

PREVIOUS EXPERIENCE IN REMOTE HEALTHCARE ENVIRONMENTS

PROFESSIONAL QUALIFICATIONS

CLINICAL QUALIFICATIONS

SPECIFIC INTERESTS

e. g Education

ARE YOU WILLING TO PARTICIPATE IN RESEARCH UNDERTAKEN BY THE I.R.H.C.

Please return completed application to : membership@irhc.co.uk

On confirmation of acceptance of membership the IRHC will request payment of membership fees applicable.