Online Booking

WINTER COMBINED MEETING
Saturday 14th January 2012

CHARTERHOUSE SCHOOL
Godalming, Surrey, GU7 2DX

CLOSING DATE FOR APPLICATIONS: SATURDAY 7th December 2011

Please note that this form is not secure. 

If you would prefer to download a copy of this form for posting please CLICK HERE

Surname
First Name
Address for correspondence
School
Your Tel No:
Your Email:
Please select your requirements: √
MOSA Delegates & Nurses Study Day £ 60
Non MOSA Delegates & Nurses Study Day £ 80
(All Doctors or Nurses who are not individual members of MOSA)
Select how you wish to pay:		Select here BACS Cheque Cash Other
Acc No: 40277360 Sort Code:18-00-02 Ref: MOSA CHARTERHOUSE MEETING Bank: Coutts and Co
		Please type the red word in lower case letters into the box below
Any comments

                       

Please submit completed form and post cheque (payable to MOSA) to
Mrs Louise Fortune, 82 Francisco Close, Chafford Hundred, Grays, Essex, RM16 6YD

Email: executive.secretary@mosa.org.uk  Telephone: 01375 483102

Places for either a delegate or guest will only be secured by the receipt of this form completed and accompanied by the correct payment.

If you have not received acknowledgement within 7 days of your posting, please contact me.