Enrolment Form

Jane Austen Day : 16 February 2008

Library Theatre, Birmingham Central library, Chamberlain Square

No. of Places:.................   Fee: £14 per person             Amount payable:....................
                       (Plus 1.2% administration for credit card transactions)

PLEASE COMPLETE IN BLOCK CAPITALS

Full Name:..........................................................................................................

(please state Mr/Mrs/Miss/Ms etc)

Address:......................................................................................................

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...................................................................................................................

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Postcode:...............................    Tel No: (evening).........................................

PAYMENT DETAILS

Cash/Cheque/PO/Credit-Debit Card (please delete as appropriate)

Please make cheques payable to 'University of Birmingham'

MasterCard/Visa No:...............................................................................

Expiry Date:.................... Security Code (final 3 numbers on back of card)..............

Signature................................................ Date...................................

Please return completed enrolment form to:

Sandra Ilott
The University of Birmingham
Selly Oak Campus
Weoley Park Road
Selly Oak
Birmingham B29 6LL

Telephone contact: 0121 414 3347     E-mail contact: s.e.ilott@bham.ac.uk

Please enclose an SAE if you require a map and/or a receipt (please tick)