EmailMe Form - Clinical Pharmacy Training Day

Name *
First Last
Title
Mr
Mrs
Miss
Ms
Dr
Prof
Other, please state
Job title *
Place of work *
Address for correspondence

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Branch - please confirm which sector(s) you work within
Hospital
Community
Prescribing Advisor
Industry
Academic
Other, please state:
Phone *
Email *
Please confirm your email address or specify an additional address we could contact you on *
Membership status *
UKCPA member
Non member
Application to follow*
*If your application is not received within 7 days you will be charged the non members rate.
Membership number
If you are joining the UKCPA at the same time as registering for the training day - please select 'application to follow'.
Work session 1: 1st Choice *
Work session 1: 2nd Choice
Work session 2: 1st Choice *
Work session 2: 2nd Choice
Work session 3: 1st Choice *
Work session 3: 2nd Choice
Work session 4: 1st Choice *
Work session 4: 2nd Choice
Work session 5: 1st Choice *
Work session 5: 2nd Choice
Lunchtime Inhaler Technique Demonstration Session *
This session will take place in the Medical Exhibition, Inhaler Technique Demonstration Zone
Dietary requirements, please state
ie, vegetarian, vegan, halal, kosher, allergies.
Special needs, please state
ie, wheelchair access, hearing loop, other
Payment option *
I will forward a cheque within 7 days
I will forward a bank draft within 7 days
I require your bank details so I can make a direct credit transfer
I require an invoice for my employer/Trust. An invoice is a request for payment and will not be sent after payment has been received
I wish to pay by debit/credit card. I will call the UKCPA office within 7 days
Cheques and bank drafts should be made payable to 'UKCPA'
If you are paying by cheque or bankdraft and require a receipt, please tick this box
Yes, please send me a receipt of my payment
Receipts will be sent to the email address given above. Receipts will only be issued once full payment has been made. Receipts will not be issued where an invoice has been raised.
If an invoice is required, please detail to whom and where the invoice should be sent
First Last
Invoices will only be sent to Trusts/Employers. The UKCPA no longer issues invoices to individuals.
Email address of finance dept/invoice recipient
The UKCPA prefers to email invoices
Purchase order number/reference code
Without this number/reference, your Trust will not settle our invoice. Please be reminded that as the individual attending this event, you are liable to settle your fee should your Trust reject the invoice
Address of invoice recipient

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Payment using this method should be made upon immediate receipt of invoice
UKCPA’s Cancellation Policy. Please select 'Yes' to confirm that you have read and understood this policy. *
We regret that we have to make a charge for cancelled registrations. If you notify us of the cancellation of your reserved place giving six weeks or more prior notice to the event, 25% of the fee will be retained. From six to three weeks prior to the event, 50% will be retained. If between twenty and eight days notice is given of the cancellation for your reserved place for a UKCPA event, 75% will be retained. There is no refund for non-attendance or cancellations made less than one week (7 days) prior to the event, whereupon the full fee will remain payable. The Association reserves the right to cancel meetings and to return the registration fee. The Association cannot be responsible for any losses resulting from such cancellation, however caused.
How did you hear about this event?
UKCPA website
UKCPA discussion board notice
In Practice announcement or insert
Event advertising flyer
Email from the UKCPA
Email forwarded from a third party
UKCPA Facebook page
UKCPA Twitter feed
UKCPA LinkedIn group
UKCPA In Focus (e-bulletin)
Journal, ie PJ, Chemist & Druggist, Clinical Pharmacist
Recommended by a colleague, friend or manager
Other, please state
Please check all that apply
The UKCPA Conference 2017 is taking place at the same venue as this event on the following two days. Would you like us to send you further information? *
Yes please
No thank you
UKCPA Conference, The Queens, Leeds, 24 - 25 November 2017
By clicking on the submit button, you are confirming that you wish to reserve a place at the clinical pharmacy training day as specified above and will be bound by our terms and conditions. *
I understand
Please include any important information or comments here