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<title>application form for SHASTD 2001 Conference</title>
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<p align="center" style="border: medium none rgb(255,255,255)"><a href="../index_htm"><img src="../_derived/home_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="home" align="middle"></a> <a href="../professional_interest/conf2001"><img src="../_derived/up_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="up a level" align="middle"></a> <a href="../forms/contact"><img src="../forms/_derived/contact_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="contact us" align="middle"></a> <a href="../sitesearch"><img src="../_derived/sitesearch_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="site search" align="middle"></a> <a href="../publicinterest/f_a_q"></a> <a href="../sitemap"><img src="../_derived/sitemap_htm_cmp_shastd2000_gbtn.gif" width="95" height="20" border="0" alt="site map" align="middle"></a> <a href="../tvdoc"></a></p>
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<h5><!--mstheme--><font color="#003366">Please note that the Conference is only open to SHASTD members<!--mstheme--></font></h5>
<form action="/" method="POST">
<input type="hidden" name="subject" value="conference application"><input type="hidden" name="forwardto" value="chrisf@shastd.org.uk"><input type="hidden" name="nextlink" value="http://www.shastd.org.uk/forms/form2.htm"><p><b>Name:</b><br>
<input type="text" name="name" size="20"></p>
<p><strong>Clinic Name and Address:</strong></p>
<p><textarea rows="2" name="clinic details" cols="34"></textarea></p>
<p><strong>Telephone:</strong></p>
<p><input type="text" name="Telephone" size="20"></p>
<p><strong>Membership Number:</strong></p>
<p><input type="text" name="membership number" size="20"></p>
<p><strong>Do you require an invoice?</strong></p>
<p><input type="checkbox" name="invoice please" value="ON">Yes <input type="checkbox" name="no invoice" value="ON">No</p>
<p><strong>Name and address for invoice if different from above:</strong></p>
<p><textarea rows="2" name="invoice address" cols="33"></textarea></p>
<p><strong>Are you vegetarian?</strong></p>
<p><input type="checkbox" name="vegetarian" value="ON">yes <input type="checkbox" name="non-vegetarian" value="ON">no</p>
<b><i style="mso-bidi-font-style:normal"><span lang="EN-GB" style="font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman";
mso-fareast-font-family:"Times New Roman";letter-spacing:-.1pt;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA"><p></span></i></b><strong>Do
you have any specific dietary needs? </strong><b></p>
<p><strong> </strong><input type="checkbox" name="special diet needed" value="ON"></b>yes
<input type="checkbox" name="no special diet needed" value="ON">no<b></p>
<p>If yes, what are they?</p>
<p><textarea rows="2" name="special diet details" cols="37"></textarea></p>
<i style="mso-bidi-font-style:normal"><span lang="EN-GB" style="font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman";
mso-fareast-font-family:"Times New Roman";letter-spacing:-.1pt;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA"><p></span></i></b><strong>Do
you require disabled access?</strong><b></p>
<p><input type="checkbox" name="disabled access needed" value="ON"></b>yes
<input type="checkbox" name="not disabled" value="ON">no<b></p>
<i style="mso-bidi-font-style:normal"><span lang="EN-GB" style="font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman";
mso-fareast-font-family:"Times New Roman";letter-spacing:-.1pt;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA"><p></span></i></b><strong>Do
you require a signer?</strong><b></p>
<p><input type="checkbox" name="signer needed" value="ON"></b>yes <input type="checkbox" name="no signer needed" value="ON">no<b></p>
<p class="MsoNormal"></b><strong>Do you require creche facilities?</strong></p>
<p class="MsoNormal"><input type="checkbox" name="creche needed" value="ON">yes
<input type="checkbox" name="no creche needed" value="ON">no</p>
<p><strong>(These are available 9.30-5.30. Other times by negotiation)</strong><b></p>
<i style="mso-bidi-font-style:normal"><span lang="EN-GB" style="font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman";
mso-fareast-font-family:"Times New Roman";letter-spacing:-.1pt;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA"><p></span></i></b><strong>If
yes, how many children? </strong><b></p>
<p><input type="text" name="number of children" size="20"></p>
<i style="mso-bidi-font-style:normal"><span lang="EN-GB" style="font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman";
mso-fareast-font-family:"Times New Roman";letter-spacing:-.1pt;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA"><p></span></i></b><strong>Are
you willing to share a room?</strong><b></p>
<p><input type="checkbox" name="will share room" value="ON"></b>yes<b> <input type="checkbox" name="will not share" value="ON"></b>no<b></p>
<i style="mso-bidi-font-style:normal"><span lang="EN-GB" style="font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman";
mso-fareast-font-family:"Times New Roman";letter-spacing:-.1pt;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA"><p></span></i></b><strong>If
yes, name of sharer </strong><b></p>
<p><input type="text" name="will share with" size="20"></p>
<i style="mso-bidi-font-style:normal"><span lang="EN-GB" style="font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman";
mso-fareast-font-family:"Times New Roman";letter-spacing:-.1pt;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA"><p></span></i></b><strong>Will
you be staying for lunch on Friday, 20th April? </strong><b></p>
<p><input type="checkbox" name="will stay for lunch" value="ON">yes <input type="checkbox" name="lunch not needed" value="ON">no</p>
<p>Your comments or question: </p>
<p><textarea rows="2" name="comments" cols="29"></textarea></p>
<p><b>Your e-mail address</b></p>
<p><input type="text" name="e-mail" size="20"></p>
<p><input type="SUBMIT"> <input type="RESET"> </b></p>
</form>
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postal address:MSF Centre, 33-37 Moreland Street, London, EC1V 8BB.
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