ROSTI Membership Application Form
Membership renewals are due on January 1st each year
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
County
Eircode
Clinic Address (if different from above)
Street Address
Street Address Line 2
City
County
Eircode
Take Photo
Email
*
example@example.com
Website
Phone Number
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Qualifications
*
Please list your qualifications, date each qualification was awarded, duration of study and awarding body.
Please upload a copy of each of your qualifications.
*
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Please tick the boxes below to verify complience with membership requirements.
I wish to apply for membership of ROSTI
I fully understand and will comply with all CPD requirements
I have a valid and up to date First Aid Responder certificate
I have valid insurance cover
I have qualified with a Higher Diploma in Orthopaedic & Soft Tissue Therapy
Please list your insurance company
Payment
Payment of €130 will ONLY be accepted by bank transfer using the following bank details: Bank of Ireland, Ballincollig. IBAN: IE30 BOFI 9026 4554 5004 14 BIC: BOFIIE2D
Please note
In the event that your application is not accepted, your fee of €130 is non-refundable. If your application is accepted, the fee will cover the membership for that year.
I hereby declare that I have made payment to ROSTI of €130 by bank transfer and the information provided is correct to the best of my knowlwdge. Signature:
Date
-
Month
-
Day
Year
Date
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