Membership Application Form 2011 - BOPA

Membership Application Form 2011
BOPA membership is for 12 months, from 1 April 2011 to 31 March 2012.
Please complete this form and post it along with your payment or direct debit form to Yvonne Blake at
the address overleaf. Alternatively, you can apply online at www.bopawebsite.org
There are three payment methods available:
Direct debit (please find form enclosed)
Cheque (to be made payable to BOPA 2011)
Bank transfer (BACS—see details overleaf)
As an incentive, BOPA is offering the following discounts for 2011/12:
• 50% off membership fees for the 1st year for all new, first-time members, who sign up using direct debit
as their method of payment
• 50% off membership fees for existing members who sign up a new, first-time member both using direct
debit as their method of payment
To qualify for the reduced fee, please ensure that existing and new members complete the membership
application and direct debit forms, posting them together to Succinct Healthcare Communications.
lesions.
ared
“I, the existing member,
wish to nominate
as a new BOPA member, entitling me to 50% off the membership.
(new member)
Full name:
Job title:
Place of work:
Department:
Work address:
Postcode:
Telephone:
E-mail:
Address for correspondence (if different from above):
Number of years in oncology:
Do you work in the private health sector?
Postcode:
Yes No

Membership type
• I am an existing member and wish to pay £45.00
• I am an existing member and qualify for the 50% discount by nominating a new member
• I attach application and direct debit forms for both members
• My membership number is:
• I am a new member and qualify for the 50% discount
What is your role?
Hospital pharmacist Academic
Community technician Oncology nurse
Pharmacy technician Network pharmacist
Community services pharmacist Pharmaceutical industry*
*Colleagues from the pharmaceutical and allied industries may join as Associate members only. Associate members are entitled
to all membership benefits except voting rights.
Area of practice (You may tick more than one box)
Clinical pharmacy
Oncology Haematology Palliative care Paediatrics
Other (specify)
Cytotoxic reconstitution
Hospital Industry Other (specify)
Research (please state research area)
Teaching
Community pharmacy
Other (please specify)
Principal areas of interest:
Adult solid tumours Paediatric solid tumours
(please specify)
(please specify)
Adult haematology/BMT Paediatric haematology/BMT
By joining BOPA you consent to your details being added to a database of BOPA members, which is
safeguarded by the Data Protection Act.
As a BOPA member, you may be sent information relating to BOPA activities and/or oncology pharmacy/
technical interests. If you do not wish to receive information from BOPA by post or e-mail, please tick this box*
*Please note that ticking this box means you will not receive information on the annual conference or yearly membership
renewal reminders.
Do you consent to approved third parties contacting you regarding meetings and study days?
Are you willing to assist BOPA by participating in reviewing and commenting on consultation documents?
If paying by BACS, please forward a copy of the remittance advice.
Bank details: Account number 01302787: Sort code 40-43-25
HSBC Bank, 1 Victoria Road, Surbiton, Surrey, KT6 4LF
Yvonne Blake, BOPA Membership, Succinct Healthcare Communications
Burton House, Repton Place, White Lion Road, Amersham, HP7 9LP, UK
Tel: +44 (0)1494 549 100 Fax: +44 (0)1494 549 111 E-mail: bopa@succinctcomms.com