Affiliate Networks

Student Affi liate: 15 / Foundation Affi liate: 25 / Pre-MRCS Affi liate: 50

To join the Student, Foundation or Pre-MRCS Affi liate Network please complete this form
and return it to outreach@rcsed.ac.uk
APPLICANT INFORMATION
Title: Click here to enter text.

First name: Click here to enter text.

Surname: Click here to enter text.

Date of Birth: Click here to enter text.

University/Hospital: Click here to enter text.

Current Year of Studies/Hospital Grade: Click

here to enter text.

Address: Click here to enter text.

Postcode: Click here to enter text.

Mobile: Click here to enter text.

Email: Click here to enter text.

PAYMENT INFORMATION

Affi liation Level applying for:

Card type:

Student

Foundation

Pre-MRCS

VISA MASTERCARD SWITCH DELTA VISA DEBIT SOLO MAESTRO

Card
Number:

Issue Date:

Debit Card Issue Number (if applicable):

Name of Card Holder: Click here to enter text

Expiry
Date:

Card Security Number (last 3 digits on

reverse):

Affiliate Networks
Student Affi liate: 15 / Foundation Affi liate: 25 / Pre-MRCS Affi liate: 50
To join the Student, Foundation or Pre-MRCS Affi liate Network please complete this form
and return it to outreach@rcsed.ac.uk
Please tell us where you heard about the RCSEd Affi liate Network? Click here to enter text.

Payment by Cheque: Cheques should be made payable to RCSEd. Please return this form to: Outreach Section, Royal
College of Surgeons of Edinburgh, The Adamson Centre, 3 Hill Place, Edinburgh EH8 9DS OR Email:
outreach@rcsed.ac.uk