Registration Form: Cutting Edge Approaches to Drug Design 2010

Registration Type:

Please underline 1 option

Member Registration

£ 60

Non-member Registration

£ 70

Student Registration

£ 30

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

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 Christine Richardson, BioFocus. 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 [ ]