HISI Membership Application Form

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Please print this page and complete the form in BLOCK LETTERS.

Then post the completed form along with a cheque made payable to ICS Skills (if applicable) to:

Healthcare Informatics Society of Ireland, Crescent Hall, Mount Street Crescent, Dublin 2.

If paying by credit card, please phone in payment on 01 6447820.

First Name
Last Name
Title
Organisation
Address


Email

Telephone

Fax

Paid-up members of the Irish Computer Society or of the Royal Academy of Medicine in Ireland are entitled to membership without further subscription. Confirmation will be sought from the parent bodies.

Tick as appropriate:	____ I am a member of the Irish Computer Society
	____ I am a member of the Royal Academy of Medicine in Ireland

The HISI annual membership fee of €25 is payable by the following methods:

Credit Card:	______ VISA ______ EuroCard/MasterCard
	We regret that we cannot take American Express.
	Card Number:	_______________________
	Expiration Date:	_______________________
	Cardholder Name:	_______________________
	Signature:	_______________________
Cheque:	Made payable to ICS Skills.

Please DO NOT SEND credit card numbers by email.

Please tick as appropriate: I do / do not agree to have my particulars included in a computer file accessible to other members under password protection, for contact purposes.

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