To: Rod Sladen, RCHS EMIAC, 25 Linden Grove, Beeston, Nottingham, NG9 2AD.

Tel:

Name (s) .........................................................

               ...........................................................

               ...........................................................

               ...........................................................

Address   ................................................................

                 ................................................................

                ................................................................

Post Code  .......................................................

Email address  .......................................................


Society (if appropriate)  .........................................................................................................

I enclose a cheque payable to RCHS East Middlands Group for £ ................ (£20.00 per head)

Please enclose a stamped self-addressed envelope for map, directions and receipt.

Please indicate here if you have any special dietary requirements:

..................................................................................................................................................................

..................................................................................................................................................................

I wish to present a report on behalf of:

..................................................................................................................................................................

I wish the following item to be included within the agenda for the reports meeting:

..................................................................................................................................................................

..................................................................................................................................................................

I have a mobility problem and require a disabled parking space (valid disabled badge required).

..................................................................................................................................................................

I wish to have display space for:

..................................................................................................................................................................

Anyone wishing to display material for sale other than on behalf of an EMIAC affiliated society or participating organisation will be expected to make a contribution to conference expenses.