Conference 2016

21-23 OctoberREGISTRATION FORM

Please complete in BLOCK CAPITALS

Surname ______First name for badge______

*Please delete as appropriate below

*Member /*Guest of the Rotary Club of______

After Jul 1 2016 will you be your club’s PRESIDENT? *YES /*NO PRESIDENT ELECT? *YES / *NO

Address______

______

Telephone______Mobile______Email______

Surname ______First name for badge______

*Please delete as appropriate below

*Member / *Guest of the Rotary Club of______

After Jul 1 2016 will you be your club’s PRESIDENT? *YES /*NO PRESIDENT ELECT? *YES / *NO

Address______

______

Telephone______Mobile______Email______

REGISTRATION FEESUp to Aug 31After Sept 1QuantityTotal

Full Registration(Friday 1.00pm – Sunday 1.00pm) £55 £65 ______£______

Full Registration (Rotaractors & their partners) £37 £43 ______£______

Full Registration(New Rotarians *see bottom of page)Free Free ______Free__

Day RegistrationFriday 1.00pm – 5.00pm £11 £13 ______£______

Day RegistrationFriday 1.00pm – midnight £33 £36 ______£______

Day RegistrationSaturday 9.00am – 5.00pm £11 £13 ______£______

Day RegistrationSaturday 9.00am – midnight £33 £36 ______£______

Day RegistrationSunday 10.00am – 1.00pm £11 £13 ______£______

TOTAL TO BE PAID: £______

A CONFIRMATION EMAIL WILL BE SENT TO YOU IF YOU HAVE GIVEN AN EMAIL ADDRESS ABOVE

Payment by Cheque:Send completed form with your cheque payable to: “Rotary District 1130 Conference” to

Alan Coleman (Conference), 122 Clayhall Avenue, Ilford, Essex IG5 0LF

Payment by Bank Transfer: SORT CODE 60-17-14 Account 87042371 “Rotary District 1130 Conference”

Please put your payment referencehere ______and thensend this completed form to:Alan Coleman (Conference), 122 Clayhall Avenue, Ilford, Essex IG5 0LF or by email to:

Register and Pay Online:Go to the Conference section atrotaryinlondon.org for instructions

*FREE REGISTRATION is being offered to new Rotarians (and their partners) inducted since 25th October 2015 providing that the partner was not already a Rotarian and that neither has attended Conference before.

(Online not available for free registrations – just email completed form to or send it to:

Alan Coleman (Conference), 122 Clayhall Avenue, Ilford, Essex IG5 0LF