ࡱ> 685M  bjbj==  WWlbbbbbbb$5********$  b*****bb***b*b**xbbx* pǃP@xx<05xVxvbbbb MEDICAL COUNCIL ON ALCOHOL 5 St Andrews Place London NW1 4LB Telephone: 020 7487 4445 FAX: 020 7935 4479 e-mail: mca@medicouncilalcol.demon.co.uk Website: www.medicouncilalcol.demon.co.ukApplication for ASSOCIATE Membership to December 2006 ________________________________________________________________________ To: The Medical Council on Alcohol 5 St Andrew's Place, London NW1 4LB ________________________________________________________________________ Full Name: ________________________________________________________________________ Preceding Title, Post nominal Awards and Qualifications: ________________________________________________________________________ Institute or Organisation: ________________________________________________________________________ Address including postcode: ________________________________________________________________________ Telephone: ________________________________________________________________________ Fax No.: ________________________________________________________________________ Email address: ________________________________________________________________________ Please indicate type of ASSOCIATE MEMBERSHIP required: (Non-medical & institutional) Individual Yes/No 28.00 Organisation Yes/No 28.00 Membership to December 2006 Membership includes a copy of the Alcohol & Health Handbook Subscription for the bi-monthly MCA International Journal Alcohol and Alcoholism is an Additional annual fee of: 45.00 Donations to MCA work are welcome at any time Please sign here if you wish any donation now and in the future to be under Gift Aid program whereby MCA can reclaim tax. 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