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<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. Becoming a member of SHASTD means that you also are a member of the
parent body, <em>amicus</em> MSF. This entitles you to support and advice on industrial
relations matters. It gives you professional liability insurance, as well as all the
professional support and information provided by SHASTD. </p>
<p>Our Membership Secretary is <a href="/">Vincent Lawlor</a>,
Whipps Cross Hospital, London.</p>
<form action="http://www.zetnet.co.uk/cgi-bin/mailform.cgi" method="POST">
<input type="hidden" name="subject" value="membership form"><input type="hidden" name="forwardto" value="vincent.lawlor@whippsx.nhs.uk"><input type="hidden" name="nextlink" value="http://www.shastd.org.uk/forms/joinshastd.htm"><input type="hidden" name="subject" value="Join SHASTD"><!--mstheme--></font><!--msthemelist--><table border="0" cellpadding="0" cellspacing="0" width="100%">
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<b><p> </b><input type="submit" value="Submit Form"> <b><input type="RESET" value="Reset Form"></p>
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<td width="100%"><!--mstheme--><font face="verdana, Arial, Helvetica"><small><small><p align="center"></small></small><a href="/"><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="../publicinterest/guest"></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>
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<td width="100%"><!--mstheme--><font face="verdana, Arial, Helvetica"><p align="center"><small><small>
postal address: SHASTD, MSF Centre, 33-37 Moreland Street, London, EC1V 8HA.
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<td width="100%"><!--mstheme--><font face="verdana, Arial, Helvetica"><small><small><p align="center"> <a href="mailto:shastdmail@fastmail.fm">electronic</small></small> <small><small>mail</small></small></a><!--mstheme--></font></td>
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<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>
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