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Registration Form: National Colorectal Cancer Nurses Annual Conference
Date: Tuesday October 11th, 2011
Time: 09:45 – 16:30hrs
Venue: Marlborough Suite, The Kings Fund, 11–13 Cavendish Square, London. W1G 0AN
Name:
Professional
Qualification(s):
Place of Work:
Clinical Nurse Colorectal
Specialist? Stoma
*Please Nurse Endoscopist
highlight all Gastro-intestinal
that apply
Liver
Other*please describe :
Contact Email:
Contact Telephone:
NCCN Member?
Membership No:
Diet Requirements?
Submitting Abstract
Oral Presentation
Poster Presentation
*Please highlight preference
Title:
Authors:


Please indicate consent to include your name and contact details on the delegate list Y/N
Please indicate if you would like to be added to become a member of the NCCN Y/N
Please note that this event is FREE for all registered nurses. However, as delegate places are strictly limited,
we would ask that each delegate registers with a provisional credit/debit card security. Please enter your
card details on page 2 of this form. NO CHARGE will be applied to the card for delegates attending the
conference.
However, registered delegates who fail to attend on the day and who have not given at least 48 hours
notice of cancellation will be charged £50.00 to cover their individual delegate expenses for the day.
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CREDIT CARD DETAILS FORM
Card type (circle/highlight):
Credit Card Number:
VISA / MASTERCARD / SWITCH MAESTRO

Card Expiry Date:
/
Card Security Code:
Card Start / Issue Date:
/
Issue Number
(Switch/Maestro only)
This section to be retained by Finance until 12th October 2011.
No charge will be made to the card unless there is confirmed as non-attendence at NCCN Conference
Cardholder's Name:
Address where card is
registered:
Flat and/or House
Number:
Road Name
Town
City
Postcode: