Registration Form

Registration Form

Nuclei at the Limits of Stability

University of Surrey, 9-11 January 2003
Title (Prof, Dr, Ms, Mr)



Surname		First Name(s)
Name preference for badge (e.g. Mr Tony Blair or Dr Frederick Strangelove)

Address	Institution
	Street
	Town
	Region
	Country
	Post Code
Tel No:			Fax No:
e-mail:

Sex (tick one): Male Female

Workshop Costs
Full workshop delegate (£180)

Includes en-suite accommodation for the nights of 9^th and 10^th January, all meals, refreshments and the workshop dinner

Special rate for EPSRC supported PhD students (£100)

Includes as above although toilet facilities may be shared in this case

Name of Supervisor:



Supervisor's Signature:

Day Delegate (without dinner) (£55)

Day Delegate (with dinner) (£105)

Total Enclosed (Due)

I have enclosed a cheque made payable to "University of Surrey" in Pounds Sterling
OR
Please bill my credit card:
Visa American Express MasterCard

Name on Card



Card Number
Expiry Date			Signature of Cardholder

OR
I will make a payment by bank transfer to the following account:

University of Surrey - Sort Code: 60-09-50 - Acct No: 58080716 - Swift Code: NWB KTB 2L
Please quote reference 11263 SD6000 on all transfers

Refunds of fees are not possible after 6 January 2003

Send this form with cheque (if relevant) to:
Professor W Gelletly, Department of Physics, University of Surrey, Guildford Surrey GU2 7XH, UK
- or fax with your credit card or transfer details to: 01483 686781