Ljósmæðrablaðið - 01.12.1991, Síða 29

MIDIRS 1991 subscription form
Please entermy 1991 subscription(s) as indicated below.
Please alloiv 28 days for delivery.
UKandBFPO RestofEurope
Rest of the world
I I Individual
£28.00
I | Student
£24-00
I | Institution
£40.00
] Individual
£36.00
[]] Institution
£48.00
] Individual
(airmail) £48.00
] Individual
(surface) £36.00
I | Institution
(airmail) £60.00
I | Institution
(surface) £48.00
Please complete in BLOCK CAPITALS
Full name ______________________________________________________________________
Occupation _____________________________________________________________________
Address: No/Street______________________________________________________________
Tdwn ________________________________________County ____________________________
Country _____________________________________Postcode __________________________
Students, please give finishinK date of traininj;_______________________________
Date ________________________________________Signature _________________________
Have you suhscrihed to MIDIRS before? YES/NO If yes, include your previous details
Where did you get this form from?____________________________________
Method of payment: please indicute your chuice:
I I 1. Cheque: I enclose my cheque for £___ made payable to MIDIRS.
I I 2. Credit card: Visa or Mastercard. I have completed the following.
Please charge í____ to my account.
Acc. no( 13/16 digits) | | | I'I TTTTTTTTTT1~I
Expiry date ___________________________ Signed ______________________
l~~l 3. Direct Debit - please see overleaf
Return this furm lu: MIDIRS, Institute of Child Health, Royal Hospital for Sick Children,
St Michael’s Hill, Rristol BS2 8BJ. Tel: 0272-251791.
Please note that this form is valid for a 1991 subscription only.
i i i i i i i rm_____________________________________________________
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