Affiliate Trichologist Member Membership Application Professional DetailsTitle:*DrMrMrsMissOtherOther Title:Name* First Last Date Of Birth:* Name of Trichology Practice*Trichology Practice Address* Street Address Address Line 2 City ZIP / Postal Code Trichology Practice Tel No:*Qualification & ExperienceQualifications and Dates*Trichology Experience*Personal Contact DetailsMailing Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country e-mail address:*Please note: this is the email address for all correspondence with the BAHRS; from time to time we will send sensitive information, please ensure that this email address is personal and secure.Tel No:*Referee's name:*NB: Referee must be a hair transplant surgeon who is a BAHRS memberThe BAHRS member who recommended I join the BAHRS:Date* I confirm that I have read and understood the BAHRS Membership Terms and Conditions and the BAHRS Code of Conduct for Affiliate Trichologist, Scientist or Researcher, Other Members, and agree to abide by them.* Yes Your data will not be shared with any third party, and the principles of the GDPR 2018 and will be adhered to. The BAHRS will use your personal data for the purposes of your involvement in Association activities. I understand that by submitting this form I am consenting to receiving information about the BAHRS by post, email, online or by phone.* YES Your application will not be processed until confirmation of support from the referee is received at email@example.com An invoice will be sent for the annual membership fee upon approval. NB. Annual membership runs for 12 months from date of payment.