20th Annual Scientific Meeting

ROCHESTOWN PARK HOTEL, CORK, IRELAND

21 - 22 SEPTEMBER 2017

REGISTRATION FORM

Title: Surname: First name:

Address: ......

...... *Postcode:......

Country:...... *Daytime Tel. No:......

Daytime Fax No:...... *Email:......

* We may need to contact you to resolve any queries over your registration so PLEASE ensure that all the sections marked with an asterisk are completed.

TYPE OF DELEGATE

Consultant Trainee Nurses/Allied Health Professional

Senior Medical Practitioners

Industry Medical Student (ID Required)

Details for Badge (Name & Hospital)

This information is required for your Delegate Badge

Name: …………………………………………………………………………………………………………………………………………………………..

Hospital:………………………………………………………………………………………………………………………………………………………..

Are you a member of AUGIS? Yes Membership number if known: ………………………

Dietary requirements:

Please inform us of any specific dietary requirements:………………………………………….

  1. REGISTRATION

Please note that we cannot guarantee registration until we receive final payment.

REGISTRATION INFORMATION

Delegate type
AUGIS/BOMSS members receive 20% discount on Scientific Meeting Registration (except Industy/Med Students) / Early Bird Rate Delegate fees before 31 July 2017 / Final Months Delegate fees from 1 August - 6 September 2017 / Onsite Delegate fees after 7 September 2017
Consultant / £330 / £380 / £430
Trainee / £200 / £270 / £330
Medical Practitioners (non-surgical) / £330 / £380 / £430
Senior / £240 / £250 / £260
Nurse/AHP / £65 / £75 / £85
Industry / £150 / £160 / £180
Medical Student (please bring ID) / £25 / £35 / £45
AMOUNT DUE / £
MINUS 20% IF MEMBER OF AUGIS / £
TOTAL AMOUNT DUE / £
AUGIS Gala Dinner at - 21st September 2017 / Gala Dinner ticket
Gala Dinner only (no member discount) / £70

PAYMENT

  1. Meeting Registration Fee £------
  2. Gala Dinner: £70£------
  3. TOTALTO PAY:£------

PAYMENT INFORMATION

FORMS RECEIVED WITHOUT PAYMENT CANNOT BE ACCEPTED AND WILL BE RETURNED

Please indicate payment card type:

  • Visa / Access / Mastercard / Visa Delta / Switch (Delete as applicable)

PLEASE ensure that you enter your 16 digit card number clearly below:

  • Credit Card No:
  • Please enter last three digits of the security code on reverse of card:
  • Valid From Date:
  • Expiry Date:
  • Issue No:
  • Cardholder’s Name:
  • Cardholder’s Address:
I have read the conditions of registration and cancellation and enclose my remittance in full

Signed Date

AUGIS CONDITIONS OF BOOKING

  1. To qualify for the reduced ‘Early Bird’ registration fee, registration forms must be returned and received at the office before 25 July 2016.
  1. A separate form is required for every delegate and every accompanying person (please photocopy if necessary).
  1. Please note that refunds will not be made on any registration or fees cancelled after 21 August 2017. Cancellations made before Monday 21 August 2017 will be subjective to a 10% administrative charge.
  1. Please ensure that you have submitted any dietary requirements and additional information. If you haven’t entered this information then please send the details to .

Please note that AUGIS 2017 will be a paperless meeting and there will instead be the AUGIS 2017 Event App.

To find out how to download the AUGIS 2017 Event App (INTO app), please visit