Registration Form
BSRM Annual Meeting 2015
‘Neuromuscular Conditions - Rehabilitation Issues & Interventions’
Tuesday 1 December 2015
at the Royal College of Physicians, London’
Personal details
Title:
Forename:
Surname:
Position:
GMC No:
(medics only)
Professional Address:
Postcode:
Correspondence Address:
if different from above address:
Postcode:
Daytime tel no:
Email address:
Details of any special needs (eg dietary or mobility):
Registration details
Please register me for the forthcoming BSRM Annual Meeting at the Royal College of Physicians details as below:
NB: Registration for 30 November programme is via the RCP http://events.rcplondon.ac.uk/details.aspx?e=3468
Session description
Cost
Discounted Package to include dinner & B&B
on 30 November and meeting on 1 December
Members £299.00*
Non-members £325.00*
NHS PAM £274.00
OR ‘pick & mix’
30 November - Dinner
£ 43.00
30 November – B&B at Holiday Inn
Regents Park, Carburton Street, W1W 5EE
£149.00 (discounted)
1 December – Conference attendance
* please circle
Members £135.00*
Non-members £155.00*
NHS PAM £85.00*
Total Cost
President: Professor Lynne Turner-Stokes | Registered charity number 293196
C/o Royal College of Physicians, 11 St Andrews Place, London NW1 4LE
Tel: 01992 638 865 | Fax: 01922 638 674 | admin@bsrm.co.uk | www.bsrm.org.uk
Sub-total
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£
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£
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£
£
£
We are able to accept payment by cheque (payable to BSRM), Card (Mastercard, Visa or
Switch - sorry not Amex) or bank transfer
Payment must be in £sterling
£
Total Amount Due
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I enclose a cheque payable to BSRM
I have transferred the total amount due direct to the BSRM Account below
Royal Bank of Scotland, Dundee Chief Office – Sort Code: 83-50-00
Account Name: British Society of Rehabilitation Medicine Account Number: 00701914
Please include the delegate’s name followed by Annual Meeting 2015 or your invoice number as a
reference.
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I authorise you to debit my Mastercard*/ VISA*/ Switch* Expiry Date
* please delete as appropriate
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Last 3 digits on signature strip
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Card number
Switch cards only
Issue number
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Valid from date
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Name and address of card holder if different from that on front of this form:
Name: _____________________________________________________________________________
Address: ____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature: _______________________________________________ Date: ____________________
OR
Please invoice
Title:
Position:
Address:
Postcode:
Forename:
Surname:
Purchase Order No: