17th Annual Scientific Meeting

SCIENTIFIC MEETING – THE SAGE Gateshead,

19 & 20 SEPTEMBER 2013

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 Overseas

Medical Practitioners Industry

Details for Badge (Name & Hospital)

This information is required for your Delegate Badge

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

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

Are you a member of AUGIS? Yes No

  1. REGISTRATION

Registration can be undertaken on-line by going to the following link:

Please note that refunds will not be made on any registration or fees cancelled afterMonday 19 August 2013. Cancellations made before Monday 19 August 2013 will be subjective to a 10% administrative charge. Confirmation of registration will be forwarded to the email address given on receipt of payment in full.

REGISTRATION INFORMATION

Delegate Type / Early Bird Rate Delegate fees before
26 July 2013 / Final Month Delegate fees from
27 July - 9 September 2013 / Onsite Delegate fees after 10 September 2013
Consultant / £330 / £380 / £430
Trainee / £200 / £270 / £330
Senior / £240 / £240 / £240
Overseas / £150 / £150 / £150
Nurses /AHPs (Nurses, Dieticians) / £65 / £65 / £65
Medical Practitioners (Physicians, Psychologists) / £330 / £380 / £430
Industry / £150 / £150 / £150
AMOUNT DUE / £
MINUS 20% IF MEMBER OF AUGIS / £
TOTAL AMOUNT DUE / £

2.TRAINING DAY - (Trainees attending the Meeting only) 18 September 2013

To be held at The Transplantation Centre, The Freeman Hospital, Newcastle.

Training Day Ticket (including Trainees Dinner): £25

3.SOCIAL PROGRAMME

Trainees Dinner - Wednesday 18 September 2013

To be held at the Pan Haggerty Restuarant

Annual Dinner- Thursday 19 September 2013

To be held at The Discovery Museum, Newcastle

Dinner tickets cost:

  1. Consultants: £70(inc VAT) c. Any other status: £50(inc VAT)
  2. Sponsors and Exhibitors: £70(inc VAT)

Please inform us of any specific dietary requirements (e.g. Vegetarian/Vegan):………………………………………….

PAYMENT

  1. Meeting Registration Fee £------
  2. Training Day: £25£------
  3. Annual Dinner:
  4. Consultants: £70 (incl VAT)£------
  5. Sponsors & Exhibitors£70 (incl VAT)£------
  6. Any other status: £50 (inc VAT)£------

TOTAL£------

FORMS RECEIVED WITHOUT PAYMENT CANNOT BE ACCEPTED AND WILL BE RETURNED

I enclose:

A sterling cheque for the total amount due made payable to “The Association of Upper GI Surgeons”

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

PLEASE ensure that you enter your card number clearly in the boxes 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:

(Block capitals)

Address

I have read the conditions of registration and cancellation and enclose my remittance in full

Signed Date

AUGIS CONDITIONS OF BOOKING

  1. If using the form manually, (page 14) this must be returned to the Conference Secretariat. If paying by cheque please make payable to The Association of Upper Gastrointestinal Surgeons.
  1. To qualify for the reduced ‘Early Bird’ registration fee, registration forms must be returned and received at the office before 26 July 2013.
  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 Monday 19 August 2013. Cancellations made before Monday 19 August 2013will be subjective to a 10% administrative charge. Confirmation of registration will be forwarded to the email address given on receipt of payment in full.

J:\MEETINGS\2013 Newcastle\Registration\17th Annual Scientific Meeting - Registration Form.docx