Please complete in BLOCK CAPITALS

1
HOSPITAL ACQUIRED PNEUMONIA ACHIEVING CHANGE
MISSION IMPOSSIBLE? London, 23-24th October
2007 WYETH REGISTRATION FORM
Please complete in BLOCK CAPITALS Title Mr
Mrs Miss Ms Prof Dr Surname
First Name
.. Department
. Hospit
al Address
.. .. Postcode
. Hospital Tel No
.. Hospital Fax No
. Home Address
..
.. Postcode
. Home Tel No
.. E-mail Address
.. Preferred address for
correspondence Hospital Home
E-mail Special dietary requirements
. Travel
I will make my own way to the meeting
(Please Tick) (Kindly
note we will reimburse your travel to the meeting
on production of a receipt attached to the travel
expense Form. Please note that travel by train
will be reimbursed on a second class train fare
or by mileage if driving.) I will need
assistance with my travel
(Please Tick) Preferred Airport of
departure.
. (Every effort will be made to arrange your
preferred airport. In the event of
unavailability of seats/flights an alternative
will be offered)
MTAZ001G Date of Preparation June 2007
2
I confirm my attendance at the above
symposium and enclose my refundable deposit of
150.00 made payable to Wyeth Postgraduate
Fund. Signature
.. Date . Please return
completed form to Anup Shah, Senior Clinical
Meetings Manager Wyeth Pharmaceuticals Huntercombe
Lane South Taplow, Maidenhead Berkshire, SL6
0PH Wyeth Pharmaceuticals wish to comply with
ABPI Code of Ethical Conduct regarding
sponsorship. Therefore we are unable to extend
invitations/sponsorship to partners of invited
delegates.
MTYG012G Date of Preparation June 2007