Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI)
Foundation Course on Hospital Infection Control at Public Health England, Colindale
between 28-30 January 2015
Registration Form
Forename(s):
Surname:
Title
Address:
Email:
Telephone:
Current post:
Hospital/Institution:
The total cost of this non-residential course is £500. A deposit of £50 is required to secure a place
on the course. Any outstanding balance is payable by eight weeks before the start of the course. If
your organisation is paying for the course, please complete the next section.
Invoice Information
Name of organisation to be invoiced:
Address (if different from previous):
Contact name of financial administrator:
Contact email:
Contact telephone:
I wish to attend the above course enclose a deposit of £50.00
Signature
Date
1
CREATED: 24.9.14
Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI)
Foundation Course on Hospital Infection Control at Public Health England, Colindale between 2830 January 2015
The deposit can be made by cheque or card payment. Cheques should be made payable to
Healthcare Infection Society. Alternatively, please supply the following information.
Card Payment Information
Card Number
Expiry Date (mm/yy)
-
-
Security Number (last 3 digits on the signature
strip at the back of the card)
/
Name and Address (per your credit card statement)
Contact Number (in case of query)
Email Address
Authorisation
I authorise the Healthcare Infection Society to charge the sum of £
Visa/Mastercard/debit card (delete as appropriate)
sterling to my
Please return your competed form and deposit to Rose Gachuhi, Healthcare Infection Society, 162
King’s Cross Road, London WC1X 9DH.
2
CREATED: 24.9.14