Application for Membership

Title

First name

Last name

Email

Phone

Organisation

Address for correspondence

Country/Region

Address

Address - line 2

City

Zip / Postal code

Position in Organisation

Date

Annual Membership Dues (select one)

Student (€5.00)

Non-student (€20.00)

Corporate (€200.00)

This application form should be submitted along with the appropriate application fee via bank transfer, as follows:

BIC: BOFIIE2D

IBAN: IE85 BOFI 9025 5731 7350 26

Please Include your name as the reference

*Membership of the IST runs from 1^st January to 31^st of December. Full fee due at any point during the year for that year.

The Irish Society of Toxicology
Cumann Tocsaineolaíochta na hÉireann