Delegate Fee £75 . Title: First Name: Surname: Job Title: Organisation: Address: Postcode: Telephone: Mobile: Email: Special dietary or other requirements: PAYMENT METHOD (Please tick your chosen method) Cheque: Payable to The Hospital for Neuro-disability and send for the attention of Phili Denning Credit/Debit Card: We accept debit and credit card payments; please contact 020 8780 5141 or Ext. 5140 to pay securely by phone. Invoice: PO or reference number: Invoicing address: Accounts payable contact Accounts payable contact tel: BACS Please send to the following Natwest Bank, RHN General Account ☐ Sort code Account no. Please send your BACS remittance form as confirmation of payment. Your BACS reference: If you are not self-funding please confirm who has authorised your attendance at this course and the funding: Name: Position: Contact email: Tel:
Title: . First Name: Surname: Job Title: Organisation: Address: Postcode: Telephone: Mobile: Email: Special dietary or other requirements: PAYMENT METHOD (Please tick your chosen method) Cheque: Payable to The Hospital for Neuro-disability and send for the attention of Phili Denning Credit/Debit Card: We accept debit and credit card payments; please contact 020 8780 5141 or Ext. 5140 to pay securely by phone. Invoice: PO or reference number: Invoicing address: Accounts payable contact Accounts payable contact tel: ☐ BACS Please send to the following Natwest Bank, RHN General Account Sort code Account no. Please send your BACS remittance form as confirmation of payment. Your BACS reference: If you are not self-funding please confirm who has authorised your attendance at this course and the funding: Name: Position: Contact email: Tel: Delegate Fee £75
DOCProgRegForm2018-2.docx