File: //home/shastd.org.uk/public_html/professional_interest/membersh.html
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8"/>
<title>membership form</title>
<link rel="canonical" href="https://shastd.org.uk/professional_interest/membersh" />
<meta name="GENERATOR" content="Microsoft FrontPage 3.0">
<meta name="Microsoft Theme" content="shastd2 000, default"><meta name="Microsoft Border" content="tb, default"></head>
<body bgcolor="#FFFFFF" text="#000000" link="#0000FF" vlink="#666699" alink="#990099"><!--msnavigation--><table border="0" cellpadding="0" cellspacing="0" width="100%"><tr><td><!--mstheme--><font face="verdana, arial, helvetica">
<p align="left"><font size="6"><strong></strong></font></p>
<p align="center" style="border: medium none rgb(255,255,255)"><a href="../index_htm"><img src="../_derived/home_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="home" align="middle"></a> <a href="../professional_interest/join"><img src="../_derived/up_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="up a level" align="middle"></a> <a href="../forms/contact"><img src="../forms/_derived/contact_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="contact us" align="middle"></a> <a href="../sitesearch"><img src="../_derived/sitesearch_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="site search" align="middle"></a> <a href="../publicinterest/f_a_q"></a> <a href="../sitemap"><img src="../_derived/sitemap_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="site map" align="middle"></a></p>
<!--mstheme--></font></td></tr><!--msnavigation--></table><!--msnavigation--><table border="0" cellpadding="0" cellspacing="0" width="100%"><tr><!--msnavigation--><td valign="top"><!--mstheme--><font face="verdana, arial, helvetica">
<p> </p>
<p>Please take a few moments to complete this 'Proposal form'. We will contact you as soon
as possible. Please note that SHASTD members must be working as Health Advisers in a UK or
Ireland GUM clinic. It is also required that they join the <a href="../professional_interest/msf">MSF trade
union</a>. Our membership Secretary is <a href="/">Dilip
Lakhani</a>. Contact him at <a href="mailto:Dilip.Lakhani@gstt.sthames.nhs.uk">Dilip.Lakhani@gstt.sthames.nhs.uk</a>
for further information. </p>
<form action="/" method="POST">
<input type="hidden" name="subject" value="membership form"><input type="hidden" name="forwardto" value="Dilip.Lakhani@gstt.sthames.nhs.uk"><input type="hidden" name="nextlink" value="http://www.shastd.org.uk/forms/joinshastd.htm"><!--mstheme--></font><table border="0" width="89%" cellspacing="0" cellpadding="0">
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Full name<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><input name="Name" type="text" size="40" value><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Proposed by<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><input type="text" name="Proposed" size="20"><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Seconded by<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><input type="text" name="Seconded" size="20"><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Home Address<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><textarea rows="2" name="Home" cols="31"></textarea><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Telephone number<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><input type="text" name="telephone" size="20"><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Work Address<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><textarea rows="2" name="workaddress" cols="31"></textarea><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Work telephone number<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><input type="text" name="worktelephone" size="20"><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Job title<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><input type="text" name="Title" size="20"><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Date started<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><input type="text" name="Startdate" size="20"><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Salary scale<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><input type="text" name="salary" size="20"><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Qualifications<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><textarea rows="2" name="qualifications" cols="31"></textarea><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Previous relevant work experience<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><textarea rows="2" name="experience" cols="31"></textarea><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Any comments or question<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><textarea rows="2" name="comments" cols="31"></textarea><!--mstheme--></font></td>
</tr>
<tr>
<td width="39%" align="right"><!--mstheme--><font face="verdana, arial, helvetica">Your e-mail address<!--mstheme--></font></td>
<td width="61%"><!--mstheme--><font face="verdana, arial, helvetica"><b><input name="e-mail" type="text" size="25" value></b><!--mstheme--></font></td>
</tr>
</table><!--mstheme--><font face="verdana, arial, helvetica">
<b><div align="center"><center><p><input type="SUBMIT"> <input type="RESET"> </b></p>
</center></div>
</form>
<p><a href="../professional_interest/membersh"><img src="../images/topengl.gif" alt="wpe2.gif (959 bytes)" width="27" height="27"></a>
<!--mstheme--></font><!--msnavigation--></td></tr><!--msnavigation--></table><!--msnavigation--><table border="0" cellpadding="0" cellspacing="0" width="100%"><tr><td><!--mstheme--><font face="verdana, arial, helvetica">
<!--mstheme--></font><table border="1" width="100%" bordercolordark="#003366" bordercolorlight="#C0C0C0">
<tr>
<td width="100%"><!--mstheme--><font face="verdana, arial, helvetica"><small><small><p align="center"></small></small><a href="../index_htm"><img src="../_derived/home_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="home" align="middle"></a> <a href="../professional_interest/join"><img src="../_derived/up_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="up a level" align="middle"></a> <a href="../forms/contact"><img src="../forms/_derived/contact_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="contact us" align="middle"></a> <a href="../sitesearch"><img src="../_derived/sitesearch_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="site search" align="middle"></a> <a href="../publicinterest/f_a_q"></a> <a href="../sitemap"><img src="../_derived/sitemap_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="site map" align="middle"></a><!--mstheme--></font></td>
</tr>
<tr>
<td width="100%"><!--mstheme--><font face="verdana, arial, helvetica"><p align="center"><small><small>
postal address:MSF Centre, 33-37 Moreland Street, London, EC1V 8BB.
</small></small><!--mstheme--></font></td>
</tr>
<tr>
<td width="100%"><!--mstheme--><font face="verdana, arial, helvetica"><small><small><p align="center"> electronic</small></small> <small><small>mail:<small><small>
</small></small></small></small><a href="mailto:lynnwil69@hotmail.com"><font size="1">lynnwil69@hotmail.com</font></a><!--mstheme--></font></td>
</tr>
<tr>
<td width="100%"><!--mstheme--><font face="verdana, arial, helvetica"><small><small><small><small><small><font face="Courier"><small>Copyright
of text and images contained on this site is held by SHASTD, unless otherwise indicated.
We request you do not use material without prior consent. The user assumes the entire risk
as to the accuracy and use of the information. This includes advice given by email. <a href="../disclaim">Full disclaimer</a></small></font></small></small></small></small></small><!--mstheme--></font></td>
</tr>
</table><!--mstheme--><font face="verdana, arial, helvetica">
<p> </p>
<!--mstheme--></font></td></tr><!--msnavigation--></table></body>
</html>