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I wish to apply for membership
I wish to reinstate my membership

Gender*		MaleFemale
Title*
Initials*
Known as*
Last name*
Region*

Primary Contact information

(Additional practices can be added once membership has been confirmed.)

Department
Hospital/House Name
House Number and Street
Locality
Town* (in CAPITALS)
County
Postcode*
Country
Exclude from 'Find a member' patients directory (i.e. if home address) Exclude from 'Search for a colleague' member directory
Daytime Telephone 1
Daytime Telephone 2
Fax
Home Telephone
Mobile Telephone
Email notices		Accept email from British Society of Periodontology? Yes No
Email address*		Email for messages from public and other members Email address for BSP mailings and newsletters
Web address		http://

Web site login details

Web site login name		Set new password		Confirm password
Login name should be lower case, and be letters, numbers and full stop only

Dentist GDC Reg No
BSDHT/BADT GDC Reg
Overseas Reg
Qualifications and year		Below are the registerable qualifications as determined by the GDC (General Dental Council). Scroll and click to add. Please remember to include the year the qualification was awarded.

Membership of other dental societies

AAP

ADI

BDA

EAO

RSM

BVDA

BSDHT

BADT

Other: Please specify:

The Society has two sections. Please indicate which is/are appropriate:

	Teachers
	Practitioners

Please tick below as appropriate

A		Armed Forces
Com		Community
H		Hospital
T		Teaching Post
U		University
G		General Practice
M		Mixed Perio/GDP
L		Limited to Perio
Ind		Industry
V		Veterinary Surgeon
Con		Consultant

Res		Research
N		NHS Practice
P		Private Practice
Ref		Referrals Accepted
E		Endodontics undertaken
Imp		Implantology undertaken
PG		Postgraduate Student *
SpR		Specialist Registrar
DwSI		Dentist with Special Interest
UG		Undergraduate Student

GDC Specialists List
SP		Periodontics
SR		Restorative

		Prosthodontics
		Endodontics

Hyg		Hygienist
BTh		Dental Therapist
Ret		Retired

* A postgraduate student will normally be expected to be enrolled in a full-time programme of taught or research-based study at a UK university or higher education institution.

If applying for Postgraduate membership please indicate the following:

Institution		Full time Part time
Course e.g. MSc		If Part time, please indicate days per week / month and course tutor
Anticipated completion date

Subscribe to email newsletters from the following BS Perio regions:

Central	Cheshire	East Anglia	East Midlands
East of Scotland	London & Home Counties	Middx Herts & Bucks	North East
North of Scotland	North West	Northern Ireland	Overseas
Oxford	South West	Southern	Wales
West Midlands	West of Scotland	Yorkshire

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