Registration Form: Cutting Edge Approaches to Drug Design 2008
Closing Date: 25th September 2008
Registration Type:
Please underline 1 option
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Member Registration
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£ 55
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Non-member Registration
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£ 65
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Student Registration
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£ 25
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Please note, students should also provide their supervisor's name and e-mail address.
Personal Details
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Name:
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Address:
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Tel:
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E-mail:
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Special dietary requirements:
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Payment Type
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Amount Paid
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Method of Payment (please circle one): Switch/Delta/Visa/Mastercard/Cheque
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If paying by credit card, please provide the following details and then send by post to Tracey or, if necessary, FAX to her on 01223 422318.
This is a secure FAX machine to which nobody has unauthorised access.
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Card Number
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Security code (last 3 digits on the back):
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Start date:
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Expiry date:
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Issue Number (switch only):
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Card Billing address:
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If receipt required (by e-mail), please tick [ ]
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