MEMBERSHIP APPLICATION FORM

Personal Details
First Name:  

Second Name:

  

Title:

  
Address:  
 
 
Zip/Postal Code:  

Country:

  
Phone (day):  
Phone (evening):  
Fax:  
E-Mail:  

 

Membership Fees & Details:- (please do not send cash)
Full membership :   
Family membership :   
Donation (£):   

Please make cheques payable to the "UK Apitherapy Society"
Are you an:-
Apitherapist?  YES/NO
Beekeeper?  YES/NO
Apitherapy Patient?  YES/NO
Would you accept referrals from potential Apitherapy patients seeking treatment ideas?  YES/NO
Do you want your name/address in the membership list   available to members only?  YES/NO
Your signature (permission for us to publish your name):     
Date:   
Please list names and addresses of others whom you think might be interested in Apitherapy?
1.
2.