ROSTI Membership Renewal Form 2022

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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Cancel of
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 €90 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 €90 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 €90 by bank transfer and the information provided is correct to the best of my knowlwdge. Signature:

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Month Day Year
Date
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ROSTI Membership Application Form

Payment

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