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Membership Form : 1st Nov 1998 - 31st Oct 1999
Membership fee for 1998 - 99 is £15 (GBP)
and should be sent with the application form, made payable to 'NPPG'
Please complete the following and return to:
Steve Tomlin
Pharmacy Department
Royal Free Hospital
LONDON NW3 2QG
United Kingdom
A: Name
| Title | Surname | Forenames |
B1: Work Address
| Institute | |
| Street | |
| Town | |
| County | |
| Post Code | |
| Country |
B2: Work Contact Numbers
| Telephone No | |
| Fax No | |
| Email address |
C1: Type of Pharmacist (tick as appropriate)
| Hospital | Community | Academic | Industry |
C2: Grade of Hospital Pharmacist
| England | Scotland | Ireland, Wales | Republic of Ireland | Other | ||||
| A/B | C -E | F and above | Basic | Senior | Principal | |||
C3: Place of work (tick as appropriate)
Paediatric Hospital |
Maternity Hospital |
Paediatric/Neonatal Unit within |
Other |
D1: Interests (tick as appropriate)
Paediatrics |
Neonates |
Both |
Signature: Date
For office use only:
| Cheque received | |
| Date: | |
| Membership number |
___________________________________________________________________________________________________
Neonatal and Paediatric Pharmacists Group
Cheque for £15 received from ____________________________________ on _____________ with thanks
| Membership Number |
Steve Tomlin (Membership secretary NPPG): Tel no: +44 (0)171 794 0500 bleep 412