Payment Includes Access to All Scientific Sessions, Refreshments and Lunch

VR in a Day 2016

REGISTRATION FORM

Payment includes access to all scientific sessions, refreshments and lunch

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)

Title: / Lastname:
Firstname: / Middle/other names:
Present Grade:
Present appointment
(please include full name of hospital/Trust and address): / Full postal address for correspondence:
Email: / Contact Tel No/Mobile:
Date registered with the GMC: / GMC/GOC/NMC number
Special requirements needed:
Dietary requirements needed:
Registration – office use only
Amount paid / £200 / £130 / Method / Cheque / Credit / Debit
Initial&Date entered onto intrepid / Initial&Date sent joining instructions
Name Badge / 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 “Moorfields Eye Hospital NHS Foundation Trust”.
Overseas bankers cheque drawn on a UK bank in pounds £ sterling 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 - 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 review our courses pages for details of cancellation fees and notice period.

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

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

VR in a day 2016, 16/21