IDEA MEMBERSHIP APPLICATION FORM

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(Please complete this form and return it to the Hon Treasurer, Mr Con Colbert, 64 Foxfield Rd, Raheny, Dublin 5.)

Name:


Address:


Tel: Home:


Work:


E mail:

I wish to join the Irish Doctors’ Environmental Association (IDEA) for the year 2012 and enclose the annual subscription/will pay by standing order (delete as appropriate).

Subscription:    Member: €40.00                 Associate Member: €40.00.
                         (Students/ Unwaged/ Pensioners: €20.00)

(Cheques should be made payable to IDEA and sent with this form to the Treasurer at the address above. If paying by standing order, please complete the form below and send/take it to your own bank. Please return the rest of this form to the Treasurer.)

My special areas of interest are:


Signed: ………………………………………………… Date: ……………………


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Standing Order

Please complete this form and return it to your own bank.

To: …………………………………..…..………Bank      Sort Code:………………

On receipt of this standing order form, please pay the sum of €…………. And then pay this sum annually from January 2, 2012 until further notice, from account number……………………… in the name of …………………………………….

To: Irish Doctors’ Environmental Association
At: Permanent TSB Bank, 2-4 Upper Baggot Street, Dublin 4.
        Sort Code 99-06-26, Account Number 00479981.

Signed: ………………………………………………… Date: ……………………