Leadership for GPs - Application form

Programme fee for 2014 is £2,500 + VAT

Please print clearly in black ink or type

Name / Date of birth
Job title
Organisation
Work address
Post code
Tel
Email

Practice Manager’s Name

Practice Manager Tel

Practice Manager Email

Home address
Post code
Tel
E-mail


This application is confidential to Leadership for GPs Programme. Please use this application only and do not send any additional material.

Return to: Louisa Coulthurst -

The King’s Fund | 11–13 Cavendish Square | London W1G 0AN

Payment details (Tick one)

n I enclose a cheque for £ ______(+ VAT) payable to King’s Fund

n Please charge £ ______(+VAT) to my/my organisation’s credit card account (delete as appropriate)

Type of card ______(Note: we do not accept American Express)

Card #______Expiry date ______

Issue # (Switch/Maestro only) ______Valid from ______

n Please invoice me/my organisation (delete as appropriate)

Purchase order number (if applicable) ______

I understand that once this application is accepted, I/my organisation will become liable for the charges, including cancellation charges.

Name and address to which invoices should be sent

______

______

Phone ______Fax ______

Signed ______Date______

n I would like to receive regular email updates from The King’s Fund

Signature Date

Terms and Conditions:
Bookings will be handled on a first come, first served basis.
Cancellation Policy:
All cancellations and substitutions should be confirmed in writing before the event.
Cancellation four weeks prior to commencement of the programme: 50 per cent of fee.
Cancellation two to three weeks prior to commencement of the programme: 75 per cent of fee.
Cancellation one week prior to commencement of the programme: 100 per cent of fee.
We are not able to make a refund for non-attendance.
The King's Fund reserves the right to cancel programmes at any stage and return any booking fee paid. In the event of cancellation, we will make all reasonable efforts to offer alternative development opportunities.
Payment:
All payment must be received by the course date or as per invoice terms.
Mastercard, Visa, Delta, Switch and Maestro are accepted.
The King’s Fund will invoice your organisation if you have requested it.
Please note that once the invoice is issued, you/your organisation will become liable for the charges, including cancellation charges.
I confirm that I have read and agree to the terms and conditions.
Signed: ______
Print name: ______ / Date: ______

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