Member by DD

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Member by DD - Pro-rata: Mar to Dec - £ 187.50

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Name, Address and Email

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Street Address (Primary) *

Supplemental Address 1

Supplemental Address 2

City *

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Email (Primary) *

Phone *

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You are not the account holder.
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Direct Debit Information

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Bank Account Number *

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My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

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Country *

County

Postal Code *

Membership information

Profession *

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I declare that the above information is true. I am in good standing with my professional regulators or relevant governing body and I am not subject to supervision and/or restrictions on my practice, nor the subject of any proceedings pending against me. I understand that being a member of the SOM does not confer entitlement to any post-nominal qualifications or use of the SOM logo. I understand that membership may be withdrawn if I act contrary to the charitable objectives of the SOM.

Declaration: *

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I agree that my personal data will be used so that the SOM can contact me regarding member benefits such as e news, renewals, regional and national events and job alerts and give my permission for my information to be passed to Oxford University Press so that I can receive the Occupational Medicine Journal, and to James Hallam so that I can be contacted about Nurse Indemnity Cover, if applicable. You are free to update preferences within the member area.

Communications Opt-In Declaration *

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Agreement Your account data will be used to charge your bank account via direct debit. While submitting this form you agree to the charging of your bank account via direct debit.

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