MOORFIELDS DUKE ELDER PREPARATION COURSE, 2016

REGISTRATION FORM

Please complete clearly and in BLOCK CAPITALS

Please note that your registration will not be confirmed without full payment via cheque or credit/debit card (please see page two)

Last/Family Name:

First Name Middle/Other name(s)

Title: Sex:

Place of study: (Full university name and address)

Present year in medical school:

Full Postal Address for correspondence (home address):

E-mail:

Contact telephone number/mobile:

Special Requirements (e.g. access):

Registration – Office Use Only
Amount Paid / £50 / £70 / Method
(Please circle) / Cheque / Credit / Debit
Initial & Date entered onto intrepid / Initial & Date sent joining instructions
Name Badge / Delegate List / Certificate and receipt
Attended: Y/N
Payment Details / Please tick () relevant box All payments to be in GB Pounds Sterling. Registrations will NOT be accepted without full payment
By Cheque/Bank draft / Payable to ‘Moorfields Eye Hospital NHS Foundation Trust’
Overseas bankers’ cheque drawn on a UK bank in pounds £ sterling or personal cheque for holders of a UK bank account
 Please deduct the
total sum due from: / Credit Card:  MasterCard  Visa
Debit Card:  Visa Delta  Switch/Maestro
Card No: …. /…./…. /…. /
Valid From date: …./…. Expiry date: …./….
Issue No (for UK debit cards only….
3-digit security code on reverse of card: …..
Amount:
Name on card:
Cardholder’s Signature:______
Billing address of card (including postcode):
______

Only submit your registration form once by email (), or post; Courses - Undergraduate Education Centre, Moorfields Eye Hospital NHS Foundation Trust, 2nd floor, RDCEC162 City Road, London EC1V 2PD, United Kingdom

By returning your completed registration form and payment details you are agreeing to the registration procedures and regulations of Moorfields Eye Hospital NHS Foundation Trust (MEH), including any cancellation policies for registration fees costs. You are also agreeing to your name and current position being included on the list of participants circulated at the course.

MEH does not accept any responsibility for any personal or financial information submitted before it is received by us. This is done so at your own risk. Once received, we process the data under data protection legislation.

NB please view our courses pages for more information about cancellation fees.

Certificates of attendance are only awarded after the final session of a course. Please bear this in mind when making your travel arrangements.

SIGNED: ……………………………………………………………. DATE: …………………………………

Patron: Her Majesty the Queen Chairman: Rudy MarkhamChief Executive: John Pelly