Membership Form

All NHS staff in Gloucestershire are entitled to join the library and Students who are currently on placement.
Please complete this form after reading the terms and conditions,then submit.

Details marked * must be filled in or we cannot process your request.

Staff or Student *
Surname *
Forename(s) *
Your Email *
Confirm Your Email *
Job Title
Work Telephone number / bleep
Ward Or Department *
On which site are you based? *
For Other, (Please State)
Professional Group
For Other, please state
Home Address *
Phone Number
Contract end date(if applies)
Employing Organisation *
For other please state
Library Card No. (If Known)

     (for accessing electronic resources)
FOR STUDENTS ON PLACEMENT ONLY
University or College
Title of Course
TERMS AND CONDITIONS *
     View Terms & Conditions