Member by DD

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Membership *

Member by DD - Pro-rata: Jul to Dec - £ 114.50

Total Amount

Account

Please enter a Username to create an account. If you already have an account please login before completing this form.

Username *

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Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores.

Password

Confirm Password

Provide a password for the new account in both fields.

Personal Details

Individual Prefix *

First Name *

Last Name *

Street Address (Primary) *

Supplemental Address 1

Supplemental Address 2

City *

Post Code *

County

Country *

Email address must be an individual account which you have sole access to.

Email (Primary individual account) *

Phone *

You should not continue with this form if any of the following apply:

You do not have a UK bank account.
You are not the account holder.
If it is a business account and more than one person is required to authorise debits on this account.

Click here to read the Direct Debit Guarantee

This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.
If there are any changes to the amount, date or frequency of your Direct Debit Society of Occupational Medicine will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Society of Occupational Medicine to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
If an error is made in the payment of your Direct Debit, by Society of Occupational Medicine or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society.
- If you receive a refund you are not entitled to, you must pay it back when Society of Occupational Medicine asks you to.
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

Direct Debit

Confirm *

Please confirm that you are the account holder and the only person required to authorise Direct Debits from this account.

Preferred Collection Day *

Account Holder *

Should be no more than 18 characters. Should not include punctuation (e.g. O'Callaghan should be OCallaghan). First initial and surname is valid. (e.g. D Watson).

Bank Account Number *

8 digits (e.g. 12345678).

Sort Code *

6 digits (e.g. 01 23 45).

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.

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province

Postal Code *

Membership information

Profession *

My Affiliations are (OH-related bodies):

I am registered with: *

If 'Other' is selected, please state here:

Other

SOM Regional Group (please select which group you'd like to join) *

How did you hear about us? (e.g. name of webinar or conference)

What is your reason for joining?

If you were recommended by another SOM member please enter their full name here:

Birth Date (This and the optional information below helps SOM to ensure that its services meet the needs of all members)

The optional information below will help SOM to ensure that its services meet the needs of all members.

Gender

Other gender (please specify)

Sexuality

Other sexual orientation (please specify)

Ethnicity

Other ethnic group (please specify)

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.

I declare that I am in good standing and not subject to restrictions on my practice. I understand that membership may be withdrawn if I act contrary to the charitable objectives of the SOM. *

Confirm

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 *

Confirm

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