AC21: 3rd Biennial International Research Festival
4th – 7th July 2006 : www.warwick.ac.uk/go/ac21
Health, Wealth & Nutrition Symposium
4th
July 2006 at The Medical Teaching Centre, University of Warwick
IMPORTANT – Unless otherwise noted, all sections must be completed. Your form will not be processed if any part is incomplete or left blank.
Section 1
This information is for your badge. Please print clearly.
Surname/family name _______________________________
First name ______________________________
Middle Initial _______________
Hospital/Institution __________________________________________________________________________
Degree ___________________
Address ___________________________________________________________________________________
This is □ Business
City ___________________________________________
Country __________________________
Phone No ___________________________________________
(area/country code)
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Home
Zip/Postcode _____________________
Fax Number _________________________________________________
(area/country code)
Email address ____________________________________________________________
Section 2
Registration Fees: Please tick appropriate box
Before
June 5 2006
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After
June 5 2006
Registration fee includes:
Refreshment breaks throughout the symposium
Buffet lunch
Standard Rate (£80 GBP)
(£90 GBP)
Early Career (£40 GBP)
(£50 GBP)
Abstract Submitted for presentation of poster
University of Warwick staff/student
Early Career delegates: must provide proof of status by
student ID or a letter written on official letterhead and
signed by a department supervisor.
To register for additional AC21 Research Festival Symposia and
other events please see the following sites:
www.warwick.ac.uk/go/ac21 or
www.warwick.ac.uk/newsandevents/events/ac21/globaled/research
Section 3
Classification: Please tick appropriate box or
boxes
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Physician
Research scientist
Pharmacist
Administrator
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Nurse
Pharmaceutical Industry
Biotechnology Industry
Media
Academic Institution
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Government
Early Career
Other
Please state ________________
Section 4
Specialities/Major Interests:
Please list top 3 interests/specialities
1.
2.
3.
Section 5
Payment:
Registration total £ _________
Please mark method of payment. Wire transfers are not accepted.
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Cheque drawn in GBP (great british pounds)
American Express
□ Mastercard
Card number ______________________________________________
Name on the card ___________________________________
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Visa
Exp date ________________
Fee to be charged £ ____________
Signature ____________________________________
A refund will be made if written notice of cancellation is
received by 4th May 2006; a £25 cancellation/processing fee
will be charged. No refunds will be made after 14th May 2006
Date _____________
We encourage participation by all individuals. If you have a disability,
notification of any special needs will help us serve you better. Check here if you
require special assistance to participate fully in the meeting.
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Yes, attached is a written description of requirements.