EofE Stroke Forum 2009 Conference Registration Form
 
Personal Details
Questions marked by * are required		 Name: *
  Email: *
*Please note that confirmation of booking will only be sent if e-mail address is provided and only after payment is received
  Job Title/Organisation: *
  Correspondence Address: *
  Post Code: *
  Telephone: *
  Dietary/special requirements:
**In line with the Data Protection Act, we will not pass your details on to any third parties If you wish to receive information on future Stroke Forum conferences and events, please tick here**
  • Yes
  • No
  Purchase Order Number:

*Please enter a purchase order number if an invoice is required and complete invoice address details below if different to correspondence address above
  Invoice address:
  If you are a member of the public rather than a professional working in healthcare, please tick here
  • Tick
  Where did you hear about the conference?
Workshops
Please indicate one preference for each session		 Session One 12.00 *
  Session Two 12.45 *
  Session Three 14.30 *
Registration

Note. Registration fees include Hot & Cold Buffet Lunch Selection suitable for Vegetarians, Coeliac (Gluten Free) & Nut Allergy Sufferers including Interval Refreshments.  Price does not include Accommodation.

Registrations and payments:  to be received by 28th February 2009



Non-Refundable Delegate Charge 75.00
  • Tick
  Early Bird Discounted Charge to 31st January 2009 60.00
  • Tick
Payment Payment Method *

Please submit this form when complete - you will then be returned to a completion page where payment options and contact details are available. Thank you.

Please take a copy of this form for your reference
(right-click and select the print option)