Registration Form BJMA 2009

 

Name in full  __________________________________________________________

 

Address ______________________________________________________________

 

______________________________________________________________________

 

____________________________________ Post code__________________________

 

Telephone ____________________________Mobile ___________________________

 

E-mail (Block Letters) ____________________________________________________

 

 

Has your address changed? Yes/No

 

 

Registration fees

	Age above 16	Age 16 - 10	Age below 10
Before 31.5.2009	£50	£25	Free
Between 1.6.09 – 11.7.09	£60	£35	£5
On the spot registration	£75	£50	£10

 

 

Please make the cheque payable to BJMA2009. No refunds after 31^st May.

Before 31^st May refunds discretionary with administrative charges deduction.

 

Name	Age	Amount
Total

 

Please send to:

Dr Lal Bahadur Mandal

Hill View

85 Dean Court Road

Rottingdean

East Sussex BN2 7DL

Email: lal.mandal@pearlmedical.co.uk