British Infection Association
MEMBERSHIP APPLICATION FORM
I wish to apply for membership of the British Infection Association
Personal Details
(please complete in block capitals)
Title
First Name(s)
Surname
Address
(for correspondence)
Postcode
Telephone number
Email address
Professional Details
Job title1
Specialty2
Employer
Address
(if different from above)
Telephone Number
Email Address
Professional qualifications
Accredited specialities
Special interest (s)3
1,2 and 3 see last page for guidance
Would you like to take part in
yes
no
1. Represent the association in media consultations
2. Clinical Service Subcommittees at regional level
Membership Category (please indicate):
Direct Debit
or BACS
Full plus
Electronic
Journal
access
Full plus
Hard copy
Journal
access
Overseas
£75.00
£90.00
£80.00
£80.00
£95.00
£85.00
Retired
(No journal
access)
Trainee
plus hard
copy
Journal
Trainee
plus
Electronic
Journal
Trainee /
Associate
(No Journal
access)
£10.00
£50.00
£35.00
Free
£15.00
£55.00
£40.00
-
Cheque
NB Payment
by cheque
incurs £5
surcharge
*Please download Direct Debit Mandate from BIA website, complete and attach to this form.
Applicant’s signature: ……………………………………………
Date:…………………………………
Please return completed form to:
Membership secretary
C/O BIA secretariat, Hartley Taylor Ltd
Suite GC Caledonian House
Tatton Street
Knutsford
Cheshire,
WA16 6AG
For Office use only: Received……..…..…....….. Approved………..…..…..… Processed………….………
1. Job Title
2. Speciality
Consultant
SpR/ ST
SHO/ FY1/ FY2
GP
SAS Dr
Clinical Scientist
Nurse
Pharmacist
BMS
Other (please specify)
Microbiology
Infectious Diseases
Combined Micro/ID
Virology
Mycology
Parasitology
GU Medicine
Tropical Medicine
Travel Health
Infection Control
Public Health
Epidemiology
Antibiotics
General Medicine
Other (please specify)
3. Special interest (s) - examples
Antibiotic resistance
Antibiotic testing
Genitourinary infections
Antibiotic stewardship
Air microbiology
Hand hygiene
Antenatal infections
Health and safety
Antiseptics
Helicobacter
Antivirals
Hepatitis
Herpes
Bacteraemia
HIV
Bioterrorism
Burns
ICU infections
Influenza
Cancer/haematology
patients
Laboartory
Care of the elderly
management/accreditation
Chlamydia
Legionella
C difficile
Listeria
CJD
Mycobacteria
Decontamination
Molecular typing/diagnosis
Dialysis
MRSA
Disinfectants
Necrotising fasciitis
E coli 0157
Neonates
Environmental cleaning
NHS management
ESBLs
Eye infections
Occupational health
Operating theatres
Orthopaedics
Food borne infections
Fungal infections
Paediatrics
Pharmaceutical industry
Renal
Respiratory
SSIs
Toxoplasma
Transplant
UTI
VRE
Virology
Waste management
Water
Other (s) - Please specify