Moorfields Femto-Phako Course, June 2015

REGISTRATION FORM

Payment includes access to all scientific sessions, refreshments and lunch

Please complete clearly and in BLOCKCAPITALS.

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 :. If other please state...... Sex:

Present grade : if not listed, please state

Present appointment: (Full Hospital/Trust name and address)

Full Postal Address for correspondence (home address):

E-mail:

Contact telephone number/mobile:.Fax No:

Date registered with General Medical Council:

GMC/GOC/NMC Number:

Special Requirements

Dietary requirements ...... Other:

Registration – Office Use Only
Amount Paid / £200 / £100 / Fellow £50.00 / Method
(Please circle) / Cheque / Credit / Debit
Initial & Date entered onto intrepid / Initial & Date sent joining instructions
Delegate List / Certificate and receipt
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 ‘MoorfieldsEyeHospital 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) 123456n/a
3-digit security code on reverse of card:
Amount: £200 / £100 / £50
Name on card:
Cardholder’s Signature: ______
Billing address of card (including postcode):

Only submit your registration form once by email (), or post; Courses - Postgraduate Medical Education Centre, Moorfields Eye Hospital NHS Foundation Trust, 162 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: …………………………………

Femto-Phako, 2015 15/27