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ABCDEFG

REGISTRATION FORM (continued)

I would not like to be contacted about future RCOG conferences and courses (please tick as appropriate)

Daytime telephone number

___________________________________________________________

Fax number ________________________________________________________________________

Email address ______________________________________________________________________ Special dietary needs (e.g. vegetarian) ______________________________________________________

How did you hear about this conference?

______________________________________________

PAYMENT DETAILS

I enclose a cheque made payable to ‘RCOG’ for £

____________________________________

OR

Please debit my credit card, as below

CREDIT CARD PAYMENTS Visa Eurocard Delta

Mastercard

Switch

Maestro

Please note we regret we cannot accept payment by American Express and Visa Electron

Card Number:

Security Code (last 3 digits on the signature strip on the back of the card):

Expiry Date:

/

IMPORTANT - If paying by Switch: Issue Number:

or Valid from date:

/

PLEASE NOTE THAT WE CANNOT PROCESS YOUR REGISTRATION UNLESS FULL CARD DETAILS (INCLUDING SECURITY CODE AND ADDRESS THE CARD IS REGISTERED TO) ARE PROVIDED

IF YOUR REGISTRATION FEE IS TO BE PAID BY YOUR HOSPITAL AND/OR EMPLOYER, WE WILL REQUIRE A REQUEST FROM THEM ON OFFICIAL LETTERHEAD BEFORE WE CAN RESERVE YOU A PLACE.

For the sum of £ (amount in figures)

_____________________________________________________________________

____________________________________________________________________________________ (amount in words)

Name and Address of card holder (if different to details overleaf) _____________________________

______ ______________________________________________________________________________

Signed

Date

___________________________________________ ____________________________

Alternatively you can register using your credit card on-line at www.rcog.org.uk/meetings

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