
Please underline 1 option
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Member Registration |
£ 80 |
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Non-member Registration |
£ 100 |
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Student Member Registration |
£ 40 |
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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.
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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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Amount Paid |
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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.
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Card Number |
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Security code (last 3 digits on the back): |
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Expiry date: |
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Issue Number and Start Date (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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