Sri Lankan Psychiatric Association (UK)

Membership application

Name………………………………………………………………………………………..

Address……………………………………………………………………………………..

 ………………………………………………………………………………………

 ………………………………………………………………………………………

Telephone & Fax……………………………………………………………………………

E-mail……………………………………………………………………………………….

I wish to become a member of the Sri Lankan Psychiatrists’ Association (UK).

Please tick whichever is applicable

 Full Membership (for all Psychiatrists of Sri Lankan origin)

Annual Membership fee:

 Consultants - £25

 Non Consultants - £20

 Associate Membership (for other professionals of Sri Lankan origin who are associated with

Psychiatry)

Annual membership fee for Associate membership - £15

I have enclosed a completed standing order (please note that payments will only be accepted as standing orders)

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

Please send the completed application form and standing order to:

The Secretary - SLPA (UK)

             "Little Orchard", 261 Kimbolton Road, Bedford, Bedfordshire MK41 8AF