Registration Form: Cutting Edge Approaches to Drug Design 2012

Registration Type:

Please underline 1 option

Member Registration	£ 70
Non-member Registration	£ 90
Student Member Registration	£ 35
Student Non-Member Registration	£ 45

Please note, students should also provide their supervisor's name and e-mail address.

Non-member registration includes membership of the MGMS until 31st December, 2012.

Personal Details

Name:

Address:

Tel:

E-mail:

Special dietary requirements:

Payment Type

Amount Paid

Method of Payment (please circle one): Switch/Delta/Visa/Mastercard/Cheque

If paying by credit card, please provide the following details and then send by post to Dr Shozeb Haider at the address on the previous page.
Please do not send credit card information by e-mail or by FAX.

Card Number

Security code (last 3 digits on the back):

Expiry date:

Issue Number and Start Date (switch only):

Card Billing address:

If receipt required (by e-mail), please tick [ ]