MEMBERSHIP APPLICATION FORM

[PRINT OFF - COMPLETE  - ADD REQUIRED COPIES OF DOCUMENTS - INCLUDE PAYMENT* AND MAIL to The Membership Secretary, ISTA, 29 Juer Street, London, England, SW11 4RE]

* you can pay using our on-line payment facilities; you will be given a reference number for inclusion in the application form

From .........................................................................................

Postal Address    ...................................................................

Zip / Postcode   .........................................................

Country

Telephone day time ...............................................................

Telephone evening .................................................................

Mobile ...............................................................................

Facsimile ............................................................................

E-Mail ............................................................................................................

I wish to join ISTA as -

[   ]  a student     [   ]   international    [   ]  national

[   ]  an affiliate   [   ]    international   [    ]  national

[   ]  a member  [   ]    international   [    ]   national

[   ] a Friend of ISTA

and enjoy the benefits currently available to a resident of my country.

I list below my qualifications, training and other personal information.  I undertstand that these will be carefully evaluated in order to determine my eligibility.

Enclosed please find copies of all the documents evidencing my training and experience (not applicable for those applying to become a Friend of ISTA),

[  ]  together with a cheque or international payment order to cover the once-off registration fee and my first

      year's membership dues (I understand that depending on the level of membership I am eligible for,   

      this membership due may be for a longer period about which you will advise me)

[  ]  I have made payment utilising your payment facility, the reference no. for this payment is .........................

My contact details should be recorded as above  [  ]

My contact details for purposes of ISTA and is directories are as follows (I understand that the starred items will show up on the practitioner search facility, which will only show full members) -

[   ]  I expressly wish for the present not to be included on ISTA's search facility

From .........................................................................................

Postal Address    ...................................................................

Zip / Postcode   .........................................................

Country

Telephone day time ...............................................................

Telephone evening .................................................................

Mobile ...............................................................................

Facsimile ............................................................................

E-Mail ............................................................................................................

My S.C.E.N.A.R. qualifications are as follows -

[qualification]     [where acquired]   [trained by whom]         [when acquired-dates of course]  [days duration]

My other qualifications are -

[qualification]     [where acquired]                   [when acquired]

If you are not medically qualified, please answer the following -

Have you completed First Aid Training and remained current                  Yes [   ]     No  [   ]

Have you received formal training in Anatomy and Physiology                 Yes [   ]     No  [   ]

If required in your country of residence, are you licenced to practice       Yes [   ]     No  [   ]

If required in your country of residence, are you insured for medical malpractice   Yes [   ]    No  [    ]

                                                                                                     professional indemnity     Yes [   ]   No  [    ]

If yes, please provide the name of your insurer, the policy number, amount of cover and the expiry date, together with an indication of any limitations or restrictions

What language(s) do / can you treat in ......................................................................................

Would you be willing to play an active role in the administration and development of ISTA, in your country and / or internationally.

Do you have or intend to form a national S.C.E.N.A.R. organisation?  Would you like to?

The following is entirely optional and will not appear on any public record -

Date of Birth

Time of Birth

Place and Country of Birth

Gender