REGISTRATION FEE: 65. Please Complete This Form and Email Back To

REGISTRATION FEE: £65. Please complete this form and email back to:

Places are limited and will be allocated on a first come, first served basis. Open to BDA members only. Tickets are non-refundable.

Location: LONDON [ ]
Title: First name: Surname:
BDA membership number:
Dental school: Year of study:
Address:
Postcode:
Tel:
Email:
Any special requirements including dietary, disabled facilities etc:
How did you hear about the seminar?

PAYMENT (please note that registrations will not be processed without payment)

Please debit my credit /debit card for £65.00 Switch/Maestro [ ] Visa [ ] Mastercard [ ]

Card number: ______

Start date: ______Expiry date: ______Issue no (Switch/Maestro only): ______

Security number ______(last 3 digits on the reverse of your card) Date of birth ______

Name of cardholder: ______

Signature (sign here only if you are posting this form): ______

Address of cardholder (if different from above): ______

______Postcode: ______If you have any queries, please call Laura on 07725 498 822 or email: