Application for Associate Membership
Personal details
Title
Surname
Forename(s)
Job Title
Dr / Mr / Mrs / Ms / Other
Address for
correspondence
Postcode
Work address
(if different from above)
Postcode
Daytime telephone no.
Email address
Mobile no.
Second email address
(if applicable)
Professional details
Experience in the field of resuscitation
Please state your reasons for wishing to join the Resuscitation Council (UK)
If you are a member of any other organisation / professional body please give details below:
Qualifications
Application for Associate Membership
December 2014
Resuscitation Council (UK)
Tel: (020) 7388 4678 | Fax: (020) 7383 0773
enquiries@resus.org.uk | www.resus.org.uk
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Please provide professional registration details below (only applicable to healthcare providers)
GMC
Registration number:
NMC
Registration number:
GDC
Registration number:
HCPC
Registration number:
Other (please specify)
Registration number:
Organisation:
Are you an Instructor for any RC (UK) courses (e.g. ALS)?
Yes 
If ‘YES’ please give details below
No 
Signature
Date
Payment details
Associate membership: £20 pa
Payment methods (Please tick as appropriate)
□ Payment by cheque:
□ Payment by credit/debit card:


Please send your cheque for £20 payable to
‘The Resuscitation Council (UK)’ together with
this application form.
Payment by card will be taken after approval. We
will contact you for your card details.
Subsequent years’ subscriptions should be paid by standing order. We will send you further details once your application
has been approved.
Please return this completed form to:
The Executive Director
Resuscitation Council (UK)
5th Floor, Tavistock House North
Tavistock Square
London WC1H 9HR
Date received
Payment by
Debit/credit card 
Outcome
Successful 
Application for Associate Membership
December 2014
For RC (UK) use only
Reviewed by
Cheque 
Cheque No.
Unsuccessful 
Resuscitation Council (UK)
Tel: (020) 7388 4678 | Fax: (020) 7383 0773
enquiries@resus.org.uk | www.resus.org.uk
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