COMMUNITY REGISTRATION FORM

London 2014
QEII Conference Centre
COMMUNITY REGISTRATION FORM
B H I V A
A U T U M N
C O N F E R E N C E
2 0 1 4
Please complete and return:
Online: www.bhiva.org
Post:Mediscript Ltd, 1 Mountview Court,
310 Friern Barnet Lane, London N20 0LD
Fax:
+44 (0)20 8446 9194
Community registration places are limited and will be allocated as fairly as possible, in principle on a first-come, first-served basis
and are up to a maximum of two registrations per community group (one per community group for Section A and Section B.
INSTRUCTIONS
•Please complete your application online at www.bhiva.org by following the appropriate links. Alternatively, complete the
form below and fax or post to the details above no later than 15 August 2014.
•If your organisation has not registered for BHIVA conferences previously, then your form needs to be accompanied by a
brief resumé of the aims and objectives of your organisation on headed paper. (Once received, this information will be
kept on file for future events).
• Please note: it is necessary for you to pay a contribution towards your attendance at the CHIVA dinner if you wish to attend.
Please complete all sections in BLOCK CAPITALS
Prof / Dr / Mr / Mrs / Miss / Ms
Family name:
First name:
Position:
Institution:
Town/city:
The above information will be used on your name badge.
Correspondence address:
Postcode:
Email:
Telephone:
Fax:
Are you a BHIVA member?
Yes
Special dietary requirements:
No
Vegetarian
Other (please specify):
SECTION A
SECTION B
BHIVA Autumn Conference 9–10 October 2014
I will attend the BHIVA Autumn Conference
Free of charge
I will attend the Drinks Reception from 1830-1930 Thursday 9 October 2014
Free of charge
Children’s HIV Association Parallel Session Friday 10 October 2014
If you are registered under Section A you do not need to complete this section unless you wish to attend the CHIVA Dinner.
I will attend the CHIVA Parallel Session
£
£20
I will attend the CHIVA Dinner from 2000 on Thursday 9 October 2014
METHOD OF PAYMENT Only forms received with full payment will be accepted and processed
TOTAL PAYMENT DUE £
(in £ sterling)
By cheque: I enclose a cheque made payable to BHIVA
By credit card: I authorise payment by credit card.
Card type: American Express
MasterCard
Visa
Issue no:
Switch
Security code (last 3 digits on reverse):
Card number:
(Switch only)
Valid from:
(Switch only)
Expiry date:
(All cards)
Name of card holder†:
Signature:
Date:
if different from above
All rates shown above are inclusive of VAT at 20% †
For official use:
CHK:
DB:
PD:
VAT Reg No. 689 5177 69
DB:
ACK: