!

12th Annual Critical Care Symposium

Thursday 23rd & Friday 24th April 2015
Manchester Town Hall, Manchester M2 5DB

REGISTRATION FORM
HOW TO REGISTER:
1. ONLINE:
To register online, please visit the April 2015 section of the Conference Calendar at www.hartleytaylor.co.uk
Debit and Credit Card payment accepted. Please note that Credit Card payments will be subject to a 3%
surcharge.
2. BY CHEQUE:
Please complete this form and return with cheque, payable to Hartley Taylor Ltd to:
Hartley Taylor Ltd, Caledonian House, Tatton Street, Knutsford, Cheshire WA16 6AG
3. DEBIT/CREDIT CARD:
Please complete this form (Personal Details and Payment Sections) and email to derry@hartleytaylor.co.uk

PERSONAL INFORMATION:
Please print clearly

Title

(delete as appropriate)

Miss / Ms / Mrs / Mr / Dr / Prof / Other:

First Name

Surname

Hospital
Department
Job Title
Address
Post Code

Telephone/Bleep No.

Email Address
Dietary Requirements
Member of ICS UK/ESICM:

Yes / No

Membership Number

REGISTRATION FEES:
ICS/ESICM
MEMBERS

Before
31st

From

NON-MEMBERS

1st

1-day

2days

1-day

2days

Consultants

170

340

210

420

SAS Doctors

140

280

175

Trainees

100

200

Nurses/AHPs

90

175

Before
31st

1-day

2days

1-day

2days

Consultants

210

420

250

500

350

SAS Doctors

160

320

200

400

125

250

Trainees

120

240

150

300

110

220

Nurses/AHPs

100

200

125

250

CONFERENCE DINNER:
Optional Dinner on Thursday 23

Payment Details
Registration Fee Due:

Dinner Ticket (50.00)

TOTAL DUE:

1. I enclose a cheque / bankers draft, payable to Hartley Taylor Ltd

2. Please charge my credit / debit card:

VISA

MASTERCAR

From
1st

SWITCH/DELTA

CARD NUMBER:

START DATE:

LAST THREE DIGITS ON REVERSE OF CARD:

EXPIRY DATE:

AMERICAN EXPRESS

Name
on
Card:
_______________________________________________________________________________________
Registered
Address
of
Card:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Signature
of
Card
Holder:
_______________________________________________________________________________________

CANCELLATION: Notification of cancellation must be sent in writing to the Conference Organiser.

Cancellations notified before 9th April (2 weeks prior to the meeting) will incur a 25% administration fee.
Non-attendance/cancellations after 9th April are non-refundable.
For further information please contact Derry (derry@hartleytaylor.co.uk)
or call 01565 621967 / 07766 196468