Full Membership Application Form

1. Name of the applicant (In block letters): Dr./Mr./Mrs./Miss./Ms …………….….…………….….

2. Full Address …………………………………………………………….……………………….……….

………………………………………………………………………………..…………………..…………..

………………………………………………………………………………………………………………..

Tel. No. ……………………………………………………………………………………………………...

3. Date of Birth ….…………………………………………………………………………………………..

4. If practising name, address and telephone number of Practice……………………………………..

………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………..

5. Period of Homeopathic practice; From………………………………..To……………………………

6. Academic qualifications…………………………………………………………………………………

(a) Name and Address of recognised College/Faculty/University where Homeopathy was studied:

………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………..

(b) Period of study in institution mentioned above:……………………….…………………………...

(c) Name of Homeopathic examination passed:………………………………………………………..

(d) Year in which passed: …………………………………………………………………………………

7. Other systems in which practising…………………………………..…………………………………

………………………………………………………………………………………………………………..

8. Registration with any other Associations/Professional Bodies…………………………………..…

………………………………………………………………………………………………………………

9. Full Membership fee enclosed: £……………………………………………….....................................

10. If accepted for membership, I agree to abide by the rules, regulations, code of practice and statements laid down by the Council of the H.M.A. If I cease to be a member due to non-payment of membership fees or for any other reason, I undertake to return my membership certificate to the H.M.A.

 

Date…………………………. Signature…………………………………………….........

11. Referees:

Name…………………………………………………………………………………………………………

Address……………………………………………………………………………………………………....

…………………………………………………………………….Tel .No…………………………...…….

Name…………………………………………………………………………………………………………

Address……………………………………………………………………………………………...……….

…………………………………………………………………….Tel. .No……………….………………..

TO BE FILLED IN BY THE OFFICE

Registration application fee received on:……………………………..………………………………....

Application: Accepted / Refused Dated...............................................................................

Signature of the Registrar.............................................................................

Fee for making entry in register and for issuing certificate received on…………………………