APPROVED

ACI2011 Registration Form
Name:
Job Title:
Department:
Hospital:
Postal Address:
Telephone:
Email:
BCIS Number:
Title: (Dr/Mr/Mrs/Ms)
Post Code:
(All registrants must be, or become, a member of BCIS)
Please indicate if you will be attending any of the Friday lunchtime breakout sessions
FRIDAY 28th JANUARY LUNCHTIME BREAKOUT SESSIONS
Lunchtime Session 1: Preparing patients and devices for structural heart procedures
Lunchtime Session 2: Training Issues
Tick Box
Payment Details:
CREDIT CARD: VISA / MASTERCARD / MAESTRO (Please circle)
CARD NUMBER:
EXPIRY DATE:
SECURITY CODE:
ISSUE NUMBER:
(Last 3 digits on signature strip on back of card)
NAME ON CARD:
Registration can also be paid by cheque to Millbrook Medical Conferences Ltd or
registration can be made online at www.bcis-aci.co.uk
Registration BEFORE
Friday 5th
November 2010
Registration AFTER
Friday 5th Nov. 2010 &
BEFORE 17th Dec. 2010
Registration AFTER
Friday 17th
December 2010
Category Total Total Total
ALL 3 DAYS -
Consultant
£255.00 £365.00 £415.00
Junior Medical &
Allied Professional £125.00 £175.00 £225.00
1 DAY RATE -
Consultant
£150.00 £200.00 £250.00
Junior Medical &
Allied Professional
£75.00 £100.00 £130.00
Drinks Reception
& Dinner
TOTAL
£45.00 £55.00 £65.00
TO BE COMPLETED BY ONE DAY REGISTRANTS ONLY - I will be attending the following day:
Please Tick Box: Wednesday 26 January Thursday 27 January Friday 28 January
Please complete and return to Millbrook Medical Conferences Ltd - Fax: 01455 550098
Suite 3, Elizabethan House, Leicester Road, Lutterworth, Leicestershire LE17 4NJ
T: 01455 552559 E: ACI2011@millbrookconferences.co.uk
www.bcis-aci.co.uk