R.P.T.I.                                             
                                                               APPLICATION FOR MEMBERSHIP

Please print and fill in this application form and return it together with the correct membership fee of €90, with a copy of your diplomas and your insurance details to the Chairperson at the following address.
Brenda Harris, 20 Laoiscara Drive, Killeens, Co, Cork.
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Personal information
Please use block capitals throughout this application form.

Surname:_____________________________________       Mr / Mrs / Miss / Ms (delete as appropriate)

Forename(s):_______________________________       Nationality:______________

Name in which your qualification was awarded, if different from your present name:
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Please enclose evidence of name change. A copy of your marriage certificate / deed poll etc.

Address:__________________________________________

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Sex:M / FDate of Birth:____________________________

Telephone:__________________________ Mobile:_____________________________

Email:______________________________

Course attended:Venue:Qualification:Date qualified:

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Please enclose a copy of your qualifications and insurance details.

I hereby declare that the information I have provided above is correct to the best of my knowledge.

Signed: ____________________________________Date:_________________