<p>British Association for the European Association for Study of Community Dentistry Dental Public Health 17th Annual Meeting</p><p>BASCD & EADPH JOINT CONFERENCE LONDON 2012 Thursday 15th (2pm) – Saturday 17th (12 noon) November Royal Institute of British Architects, Portland Place, W1B 1AD</p><p>REGISTRATION FORM</p><p>Title Name Address </p><p>Postcode Tel. No. Email</p><p>EADPH Registration No:- (if applicable) GDC Registration No:- (or other registration number for CPD purposes) (if applicable)</p><p>* EARLY BOOKING before 15th Sep 2012 is recommended to avoid £60/€72 late booking fee *</p><p>BOOKING OPTIONS:- (£) or (€) – PLEASE STATE CLEARLY IN ‘TOTAL’ BOX</p><p>Total £ / € 1. COMPLETE CONFERENCE PACKAGE:- Reception (Thursday 15th), Dinner (Friday 16th) & Lunches & Refreshments</p><p>BRITISH £ EURO € Member rate: £320 €396 Non-member rate: £420 €521 Student/Retired rate: £290 €360</p><p>2. CONFERENCE DAY PACKAGE (without Reception & Dinner) British Association for the European Association for Study of Community Dentistry Dental Public Health 17th Annual Meeting</p><p>Lunches & Refreshments</p><p>Member: £210 €260 Non-member: £310 €384 Student/Retired Rate: £190 €236</p><p>3. FRIDAY DELEGATE ONLY Lunch & Refreshments</p><p>Member: £120 €149 Non-member: £150 €186 Student/Retired: £100 €124</p><p>4. CONFERENCE RECEPTION Additional for Day Delegate only £42 €52</p><p>5. CONFERENCE DINNER Additional for Day Delegate only £70 €87</p><p>NB – If applying after 15th September – please add £60 / €74 - late booking fee</p><p>SUB-TOTAL for DELEGATES</p><p>ACCOMPANYING PERSON:-</p><p>1. CONFERENCE RECEPTION £42 €52</p><p>2. CONFERENCE DINNER £70 €87</p><p>SUB-TOTAL for ACCOMPANYING PERSON</p><p>TOTAL ENCLOSED</p><p>PLEASE STATE CLEARLY – (£) or (€) – THANK-YOU</p><p>British Association for the European Association for Study of Community Dentistry Dental Public Health 17th Annual Meeting</p><p>Special requirements: Please advise of any special dietary or other requirements e.g. mobility, hearing etc</p><p>………………………………………………………………………………………………………………………..</p><p>Payment/confirmation of BACS must accompany the registration form.</p><p>I am paying by the following method (please tick one only)</p><p>1. Cheque (personal)* </p><p>2. Electronic Payments (personal)* </p><p>3. Cheque (employing organisation)  Please tick if you require an invoice </p><p>4. BACS (employing organisation)  Please tick if you require an invoice </p><p>* preferred payment method</p><p>Further guidance on each of these payment methods is outlined below</p><p>1. Cheques (personal) Please make cheques payable to BASCD and send together with a completed application.</p><p>2a. Electronic Payments (personal) in Sterling Payment can be made in Sterling via internet banking to BASCD sort code 162406, account no. 10223851. </p><p>Please ensure that you enter your initials followed by EADPH as the payment reference. </p><p>2b. Electronic payment (personal) in Euros Payment can be made in Euros via internet banking to: Account name: British Association for the Study of Community Dentistry Account address: 66 South Mall Cork Sort code: 934178 Account number: 16225027. IBAN: IE12 AIBK 9341 7816 2250 27 BIC: AIBKIE2D British Association for the European Association for Study of Community Dentistry Dental Public Health 17th Annual Meeting</p><p>Please ensure that you enter your initials followed by EADPH as the payment reference. </p><p>3/4. Cheque/BACS Payments (employing organisation) If your employer will be sending a cheque or BACS payment please enter the name of your employing organisation below and send a COPY of this completed form to secure early registration. The original should come from your employing organisation. If a invoice is required, please indicate this on your registration form. Please specify if you would prefer the invoice to be raised in Sterling or Euros.</p><p>Name of Employing Authority/Trust:...... </p><p>Original forms should accompany cheques or be sent with BACS payment details to: EADPH, C/o VSM Europe Ltd 8 Salmon Fields Business Village Royton Oldham OL2 6HT Tel : 0161 665 2882 Fax : 0161 665 5884 email : [email protected]</p><p>SPECIAL INTEREST WORKING GROUPS - THURSDAY 2.45pm PLEASE IDENTIFY YOUR CHOICE OF WORKING GROUP AS BELOW – if not chosen a group will be allocated</p><p>PLEASE CHOOSE WHICH GROUP YOU WOULD LIKE TO ATTEND & TICK RELEVANT BOX:- (ONE GROUP ONLY – 1st choice & 2nd choice )</p><p>PLEASE TICK PLEASE TICK</p><p>1st Choice 2nd Choice British Association for the European Association for Study of Community Dentistry Dental Public Health 17th Annual Meeting</p><p>1. Caries Epidemiology and Prevention - Chair: Klaus Pieper</p><p>2. Gerodontology - Chairs: Jacques Vanobbergen and Luc Devisschere</p><p>3. Periodontal Epidemiology - Chairs: Roos Leroy and Kenneth Eaton</p><p>4. Prevention of Oral Cancer - Chair: Katrin Hertrampf</p><p>5. Tooth Surface Loss/Erosion - Chair: Carolina Ganss</p><p>6. Quality of Life - Chair: George Tsakos</p><p>7. Dental Public Health Education - Chair: Jenny Gallagher</p>