SDUI Full Membership Application

SDUI Full Membership Application
Name (as it appears in IMC/Passport)

First NameMiddle NameLast Name
IMC reference No
If No IMC No. please provide your SMC reference Not preceeded by S
Email
example@example.com
Phone Number
Address

Address line 1

Address Line 2

CityCountry

Eircode/Postal codeCountry
Current work locaion:
If Other Please specify :
Speciality Domains
Choose your speciality area
Sub Speciality if applicable :
e.g Cardiology , Neurosurgery , Immunology
Professional Role
Years of residency in Ireland:
Which SDUI activity are you interested in? (you can use more than one option)

Other
Other areas of interest

Other
Preferred payment method ?
Personal information and privacy policy
We encourage all our members to pay their fees via a direct debit/standing order
Our Bank details:

Sudan Doctors Union CLG
Acc No. 20844047
NSC 937088
BIC AIBKIE2D
IBAN IE51AIBK93708820844047

Monthly fees:

€10 for NCHD

€20 for consultants
Should be Empty: