UKPEW 2008 Registration Form

                                                http://ukpew.org/
                                                Imperial College London, UK
                                                3 and 4 July 2008

FAO: Dr William Knottenbelt, UKPEW 2008 Registration
Fax form to: +44 20 7581 8024

APPLICANT DETAILS 
(Duplicate section as necessary for multiple registrations on the same 
credit card)

First name:
Last name:
Paper number,if you are presenting a paper:             

Institution:                                                    
Address:                                                                
                                                                        
City:                                                                   
Country:                                                                
Phone:                                                                  
E-mail:                                                                 

REGISTRATION DETAILS

Select registration type:                       __ STUDENT      __ FULL

Full registration fee:                          __  @ GBP 130   
Student registration fee:                       __  @ GBP  80   
Full registration fee
plus accommodation Thursday night:              __  @ GBP 190   
Student registration fee
plus accommodation Thursday night:              __  @ GBP 140   
Accommodation Wednesday night:                  __  @ GBP  70   

TOTAL:                                                GBP             

All registration fees include one dinner. For extra rooms, nights or 
dinners contact 2008@ukpew.org with "Extra Query" in the subject
line. 


Special dietary requirements: None                   __    
                              Vegetarian             __
                              Other (please specify) ___________

Interested in a tour of Queen's Tower (for details see website): 
                              Yes/No




CREDIT CARD DETAILS

We can NOT accept American Express or Diners Club. Please do NOT send
your card details via e-mail but fax them. If you want to send them
via encrypted e-mail please contact 2008@ukpew.org with the subject
line "Encryption question".

Select card type:             VISA         MASTERCARD         MAESTRO

Name (as it appears on card):                   

Card number:                            |______|______|______|______|          

Expiry date [MM/YY]:                    |______/______|
Valid from  [MM/YY]:                    |______/______|
Issue number (if MAESTRO card):         |______|
Security Code (3 digits):               |______|

Please debit TOTAL from my card (Signature):                                  


Date:                   





If you would like to transfer the money electronically, the college bank 
details are:
Bank:  National Westminster Bank plc
Address:  18 Cromwell Place, South Kensington, London, SW7 2LB
Sort code:  51-50-01
Account:  00600032
Account name:  Imperial College of Science Technology and Medicine
Swift Code:  NWBKGB2L

Please mark the transfer for:
"COHPC G18662 UKPEW2008"

When you have sent the registration form please send an e-mail to
2008@ukpew.org and we shall acknowledge the receipt of that e-mail and
the receipt of the registration form.


FAO: Dr William Knottenbelt, UKPEW 2008 Registration
Fax form to: +44 20 7581 8024