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Full name:





Employer name:

Your current role:

Membership Number:


Full Title, Dates & Location of The Course or Conference You Will Be Attending:

If you are presenting a poster or making an oral presentation please give the title of the presentation:

Please state how presenting or speaking at the conference will promote the exchange and development of knowledge on working with people with acquired brain injuries:

What are the likely costs of the event?:

Course fees:

Travel fees:

Accommodation fees:

Total Costs:

Please give details of any employer contribution or confirm that funding is not available from your employer:

Additional information: