CONNECT CENTRE FOR INTERNATIONAL RESEARCH ON INTERPERSONAL VIOLENCE AND HARM
CONFERENCE
Thursday 12 May 2016
9.30 am. – 4.30 pm.
Brockholes Conference Centre
PrestonPR5 0AG
APPLICATION FORM
The early booking rate ends on 31 March 2016
The Conference package fees are included below for your information.
Full Price:
£85 pp. (£75 pp. if booking before 31 March 2016)
Students/Third Sector Organisations:
£55 pp. (£45 pp. if booking before 31 March 2016)
Lunch provided & free parking
Conference Booking Form
Please return this application form by email or post to: Lorna Burrow,School of Social Work, Care and Community University of Central Lancashire, Room 204, Brook Building, Preston, PR1 2HE
01772 893936
Delegate Information
Title:
First name(s):
Surname:
Workplace name:
Workplace address1:
Workplace address2:
Workplace address3:
Workplace address4:
Telephone numbers:
Number:
Mobile number:
Email address:
Do you have special dietary requirements? Yes No
If yes, please give details:
Do you need any assistance with mobility and / or access? Yes No
If yes, please give details:
Do you have any technical requirements? Yes No
If yes, please give details:
May we use your contact details on the delegate list? Yes No
Payment methods (please check the relevant box below)
I am paying by Bank Transfer ☐
I am paying by cheque ☐
My workplace will pay via invoice ☐
I have contacted the Cashiers and paid £______(please indicate amount) bycredit card ☐
Please tick here if you require a receipt ☐
Please telephone the Cashiers on 01772 892184 or 01772 892186. As well as providing your credit card details, please provide the Project Code (CYX122).
If you are paying by Bank Transfer:
Payment can be made directly into the University bank account. Details of the bank account are below:
Account Name: University of Central Lancashire
Account Number: 20560332
Sort Code:20-69-85
IBAN: GB04 BARC 2069 8520 5603 32
Swift Address: BARCGB22
Bank Address: Barclays Bank, 38 Fishergate, Preston, Lancashire, UK PR1 2AD
IMPORTANT - When paying via bank transfer, please quote your name and the account (CYX122)and ‘Connect Conference’ in the remittance/narrative field.
If you are paying by Cheque or Invoice:
Payments via cheque (cheques to be made payable to ‘University of Central Lancashire’) should be sent to lorna Burrow at the address below.
To pay by invoice, please send contact details for the person in your organisation who has agreed to pay the invoice to:
Lorna Burrow
University of Central Lancashire
Brook Building, Room 204
Preston, PR1 2HE
01772 893936
When paying via cheque, please quote the conference name, delegate name and the account (CYX122) and ‘Connect Conference’ on the back of the cheque. .
Should you have any queries at all regarding your payment please contact Lorna Burrow on 01772 893936. Alternatively you can contact us via emailat:
We look forward to welcoming you to the conference.