SICS Application Form

Name *

Title *

Profession or Speciality *

Trainee * Yes
No

CCT Date

Position or Grade *

Main Hospital or Rotation *

Hospital/Work Address *

Post Code *

SICS Region (the main region you work in) * North - includes Highlands, Grampian, Tayside, Orkney, Shetland and Western Isles
East - includes Lothian, Borders and Fife
West - includes Dumfries and Galloway, Ayrshire and Arran, Lanarkshire and Forth Valley
GGC - includes GGC and GJNH
Outside Scotland

Your Email Address *

Please Confirm Your Email Address *

Your Contact Number *

Your Home Address *

Your Post Code *

Membership of the Scottish Intensive Care Society as a * Full Member (Non-consultant career grade/Consultant) at 60 GBP per annum
Full Member (Trainee) at 40 GBP per annum
Associate Member at 25 GBP per annum
Retired Clinician at 25 GBP per annum
Student Member at 12 GBP per annum

I am a member of the UK Intensive Care Society * Yes
No

I am a member of the AAGBI * Yes
No

Please send mail to my * Home address
Hospital/work address

Membership Application Form