British Paediatric Neurology Association

2004 Conference Sheffield Booking Form

Please return to: BPNA Secretariat, 204 Greenmount Lane, Heaton, Bolton, BL1 5HZ, UK

Delegate Details:

Title: ______________ First Name: _______________________________________________________

Surname: ________________________________________ Are you a trainee? Yes/No

Institute: __________________________________________________________________________________

Address for correspondence: __________________________________________________________________

__________________________________________________________________________________________

Telephone: _____________________________________ Fax: ___________________________________

Email: ____________________________________________________________________________________

Conference Attendance:

Full conference attendance 23-25 January 2004

Fee £400 if booked before 20 September, £440 if booked later £_______

(Fee includes all accommodation and meals, including one ticket to the Gala Dinner)

Please indicate your choice of hotel (1^st, 2^nd or 3^rd). Allocation will be made according to availability.

 Novotel  Hilton Hotel  Royal Victoria Holiday Inn

I would like to join the excursion to:

 Abbeydale Industrial Hamlet  Bolsover Castle

Day delegate attendance

Please indicate which day(s) you wish to attend and if you will require evening meals or accommodation.

Friday, 23 January 2004:	Conference attendance Dinner at the Millennium Gallery Accommodation	__________ @ £88 __________ @ £20 __________ @ £75
Saturday, 24 January 2004:	Conference attendance Afternoon excursion Gala Dinner Accommodation	__________ @ £88 __________ @ £10 __________ @ £40 __________ @ £75
Sunday, 25 January 2004	Conference attendance	__________ @ £88
	TOTAL	£_________

Special Requirements:

________________________________________________________________________

Payment Method:

 Cheque enclosed payable to ‘BPNA - Conference’  Invoice my Trust  BACS

NOTE: We can only invoice the Trust direct if your booking is received before 21 November 2003.

Trust Invoice Address: _________________________________________________________________

____________________________________________________________________________________

For the attention of:______________________________ Purchase Order No:______________________