Membership no.

Application for International Associate Membership

Please use this form if you have a proven academic or professional interest in microbiology and live
outside the UK and Ireland. This category is for those who do not desire the full range of benefits
available to Full Members.
1. Personal details
Surname/Family name
Forenames
Gender (tick box)

h Male

Title (Prof/Dr/Mr/Mrs/Miss/Ms)

h Female

Date of birth

Academic qualifications
Present occupation
Workplace address (give full details including department within institution/company)

Post/Zip code

Telephone no.

ext.

Email
Home address

Post/Zip code

Telephone no.
Which address should we use to contact you?

h Work place

h Home

2. Membership
I wish to apply for International Associate Membership.

h I am a resident of a country outside the UK and Ireland (subscription 20/US$42/24)

h I am a resident of a lower-middle-income country* (subscription 20/US$42/24)

h I am a resident of a low income country* (subscription free)

*As classified by the World Bank.

3. Interests and Expertise

Please tick as many of the boxes as are appropriate:
Area of interest and expertise:

h Microbial diversity and evolution

h Education

h Food microbiology
h Clinical and medical microbiology

h Environmental microbiology
h Industry/Biotechnology

Area of specialism:

h Bacteria

h Viruses

h Fungi

h Protozoa

h Algae

h Archaea

h Prions

PTO

4. Declaration
1. I agree to be bound by the Memorandum and Articles of Association and the Byelaws of the Society, as amended from time to
time.
2.

Data Protection Act 1998. I understand that information provided by me on this form will be processed by the Society for
General Microbiology and will be used for the purpose of:
(i) providing me with the benefits of membership and goods and services ordered, and for billing and subscription renewal
(ii) providing me with information on products and services that is included in regular mailings of Microbiology Today
(iii) providing me with email alerts about Society activities, unless I have indicated otherwise below.

If you do not wish to receive email alerts about Society activities, please tick here

Signature

Date

Please submit a short CV with your application.

I have attached my CV.

5. Payment
Please select from one of the payment options below.
Payment can be accepted in Sterling, US dollars or Euros (unfortunately we do not accept Euro cheques).

Option 1

I wish to pay 20/US$42/24 by Debit/Credit Card. No cards other than those indicated below can be accepted.

I authorise you to debit my Debit/Credit Card to the value of

Signature

/ US$

(in total).

Date

Cardholders address (address to which your Credit Card statement is sent)

Card type (please tick one box only)

Mastercard Credit

Visa Credit

Mastercard Debit

Visa Debit

Maestro/Visa Electron

My Debit/Credit Card number is:

Card security
code
Valid
from

Option 2

Expiry
date

Issue no.
where applicable

I wish to pay by bank transfer (BACS). BACS details will be sent upon request

Send completed form, together with remittance, to:

Society for General Microbiology (Membership Office), Charles Darwin House, 12 Roger Street, London WC1N 2JU, UK
[t +44 (0) 207 685 2691; e members@sgm.ac.uk; w www.sgm.ac.uk]

Company Limited by Guarantee Registered in England No. 1039582 | Registered Office as opposite | Registered as a Charity in England and Wales, No. 264017 | A charity registered in Scotland, No. SC039250

Sept 2014