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HAS Membership Application Form Please print this form out, complete it in CAPITAL LETTERS, and post it to: Dr A Kuipers , The Old School, Nesscliffe, Shrewsbury SY4 1DB Title:............................. First Name (s):.......................................................................................................................... Surname:.................................................................................................................................. Honours and Qualifications:....................................................................................................... Address:............................................................................................................ ............................................................................................................... ................................................................................................................. Post Code / ZIP:.................................................................... Telephone:.............................................................................. Fax:....................................................................................... E-mail:................................................................................................. Profession:................................................................................... Present or Last Appointment:............................................................................... ............................................................................................................................... Particular interests in the History of Anaesthesia:.......................................................... ................................................................................................................................. ................................................................................................................................... Signature: ................................................................... Proposed by: ............................................................. |