Green Light Pharmacy

Pre-registration Study Day Programme 2015-16 Booking Form

(Please ensure all sections are completed)

Student Details

(please complete ONE booking form per student)

Title (Mr, Mrs, Miss etc.)
First name
Surname
Home address
Phone number (mobile)
E-mail address (please
write clearly)

Tutor Details
Title (Mr, Mrs, Miss etc.)
First name
Surname
Pharmacy name & address
Phone number (work)
E-mail address (please
write clearly)
Please circle which day of the week you
would like to attend each session

FRIDAY
SATURDAY

Would you like to book the additional

December Study Day on MUR
accreditation? (circle YES/NO)

YES

NO

Is this booking part of a group booking?

(circle YES/NO)

YES

NO

If yes please provide the contacts name

for the group
If yes & part of a pharmacy group, what is
the name of the pharmacy chain or
pharmacy buying group?
How many students would you like to
book?

Invoicing & payment details

Name of the person responsible
for payment of the invoice
Billing address (including post
code)
Phone number
E-mail
Fax

Please send completed forms to Green Light Pharmacy by :

e-mail: simon@greenlightpharmacy.com
post:
Simon Harris, Green Light Pharmacy, 62-64 Hampstead Road, London, NW1

2NU

fax: 0207 387 3233

Places are limited & will be confirmed on a first come first served basis.

For further information please call Simon Harris on 07811 214

456