Thursday 1 March 2007 – Deadline for ‘Early Bird’ registration



Delegate Details: (* Information is mandatory)

*Full name: Prof / Dr / Mr / Mrs / Ms

*Address:

*City………………………….*Postcode………………………………*Country

*Tel *e-mail

*Current Post ...... Health Education Region*

BCS Member: Yes/No BCS Membership Number*:………………………………….

If registration is being made by an agency or company on behalf of a delegate, please make sure you give full contact details of the delegate as required above.

Registration Fee: BCS members - £100 (inclusive of VAT). Non BCS members - £150 (inclusive of VAT).

Accommodation to be booked by attendee, at their own expense.

Payment Method:

CHEQUE £……………….□ (Please make cheque payable to British Cardiovascular Society)

CREDIT CARD £……………………□ (Please provide your Card details below)

BANK TRANSFER DETAILS £……………………□ (Please arrange transfer to the below account, notifying BCS once the transfer has been processed on courses@)

Name of Account: British Cardiovascular Society, Account No: 26771071, Sort Code: 56 00 31,

IBAN Code: GB46 NWBK 5600 3126 7710 71, Swift: BIC: NWBKGB2L

Credit Card Payment Details

Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Switch / Maestro / Visa / MasterCard (please circle)

Valid from _ _ / _ _ Expires end _ _ / _ _ Issue number (Switch/Solo) _ _ Security Code _ _ _

Signature

Cardholder’s name, address and telephone number (if different from above)

Name

Address

Email: Tel:

Please return your completed form to Anna Kassai, BCS Courses, 9 Fitzroy Square, London, W1T 5HW, or email to courses@

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