Please underline 1 option
Member Registration |
£ 80 |
Non-member Registration |
£ 100 |
Student Member Registration |
£ 40 |
Student Non-Member Registration |
£ 50 |
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, 2014.
Name: |
Address: |
Tel: |
E-mail: |
Special dietary requirements: |
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
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 [ ] |