58th Rankine Dinner Wednesday 21st March 2018 at 7.30pm Queen’s Tower Room, Sherfield Building, Imperial College London, Exhibition Road, SW7 2AZ Request Form (Note: Bookings are not guaranteed until payment has been made by credit card) Please return to Shelagh Fleming at by 31st December 2017 Title (Mr, Mrs, Ms, Dr, Prof) First Name Surname BGA/ICE Membership Number Contact e-mail address Primary Host Contact telephone Company Address No of individual places required including Primary (maximum = 9) Host No of of 10 places each tables required including primary (maximum = 2) OR host(s) Title (Mr, Mrs, Ms, Dr, Prof) First Name Alternative host Surname for 2nd table if BGA/ICE Membership Number required/available Contact e-mail address Contact telephone Title (Mr, Mrs, Ms, Dr, Prof) First Name Surname Booker (if not host) BGA/ICE Membership Number Contact e-mail address Contact telephone
58th Rankine Dinner Wednesday 21st March 2018 at 7.30pm Queen’s Tower Room, Sherfield Building, Imperial College London, Exhibition Road, SW7 2AZ Request Form (Note: Bookings are not guaranteed until payment has been made by credit card) Please return to Shelagh Fleming at by 31st December 2017 Primary Host Title (Mr, Mrs, Ms, Dr, Prof) First Name Surname BGA/ICE Membership Number Contact e-mail address Contact telephone Company Address No of individual places required including Primary Host (maximum = 9) OR No of tables of 10 places each required including primary host(s) (maximum = 2) Alternative host for 2nd table if required/available Title (Mr, Mrs, Ms, Dr, Prof) First Name Surname BGA/ICE Membership Number Contact e-mail address Contact telephone Booker (if not host) Title (Mr, Mrs, Ms, Dr, Prof) First Name Surname BGA/ICE Membership Number Contact e-mail address Contact telephone
2018_RD_request_form.docx