CONFERENCE REGISTRATION FORM

(Please complete this form, even if you have submitted an Initial Interest Form)

Title:
*

First Name:
*

Surname:
*

Title:
*

Organisation:
*

Address (In Full)
*

Tel:
*

Fax:

Email:

Name of Personal Assistant (if any)

First Name: Last Name:

Name of Accompanying Person (if any)

First Name: Last Name:

Arrival Date:
*

Departure Date:
*

Please inform us of any special requirements, e.g dietary, access etc.

Payment Details

Registration fee for Delegates (includes conference, social events) - €620

Accompanying Person/Personal Assistant Fee (includes social events only) - €214

Total Amount Payable € *

Payment Methods

(An invoice will be issued following receipt of your registration from)

Please tick preferred method of payment:

By Credit transfer to:

Account Name: Rehab Enterprises LTD (Current Account)
Iban No: IE69 BOFI 9000 1793 857512
Bic Code: BOFIIE2D
Bank & Branch: Bank of Ireland, 2 College Green, Dublin 2
(Please use delegate name as reference)

Bank Draft / Cheque Payment in the amount of the total above (payable to: Rehab Enterprises Ltd. and post the the address below)

Ann O'Beirne, Rehab Group, Roslyn, Sandymount, Dublin 4

By Credit Card:

Please fill in the Conference Credit Card Form and email/post/fax to:

Ann O'Beirne, Rehab Group, Roslyn, Sandymount, Dublin 4
Tel: + (353) 1 205 7265
Fax: + (353) 1 205 7373 Email: workabilityconference2010@rehab.ie