NZ Society of Endocrinology (Inc.)

APPLICATION FOR ENROLMENT AS A STUDENT MEMBER

Name in full: (Surname)_________________(Given names)__________________________

Address: Business__________________________________________________________________________

____________________________________________________________________________________________

Phone_______________________ Fax_______________________ Email_________________________

Date of Birth ____________________________

Title (Dr, Mr, Mrs, Ms, Miss) ________________

University degrees or other academic qualifications (university, degree, date of graduation)

_______________________________________________________________________

In the Department of _____________________Course (PhD, Masters, etc)_____________

Confirmation of student status (Head of Department to sign)__________________________

Major Endocrine Interest (Pituitary/Adrenal/Thyroid etc.) ______________________________

Tick one only: Registered Clinician ___ Basic research ___ Both clinical and basic research ___

I AGREE TO ABIDE BY THE RULES OF THE NEW ZEALAND SOCIETY OF ENDOCRINOLOGY (INC.)

Date of Application: _____________________ Signature: __________________________

This application is proposed by _________________ and seconded by ________________

(both must be existing members)

THIS FORM SHOULD BE RETURNED TO THE NZSE SECRETARY:

Dr Margaret Evans

Endolab, 21 St Asaph St, Christchurch Hospital

Private Bag 4710, Christchurch, New Zealand

Email: margaret.evans@cdhb.govt.nz