Roche Diagnostics – Lung Cancer Advisory Board |

* = required field

First name*

This field is required

Last name*

This field is required

Institution name*

This field is required

Email address*

Required. Please check email is formatted correctly

We will arrange your accommodation

I would like the meeting organisers to arrange my accommodation
No accommodation required

Hotel arrival date (dd/mm/yyyy)

This field is required

Hotel departure date (dd/mm/yyyy)

This field is required

Participants are asked to arrange their own travel

I will organise my own travel and will request a refund
I will organise my own travel and will not request a refund

We will arrange your travel to/from the meeting

I would like the meeting organisers to arrange my flights
I would like the meeting organisers to arrange my trains I would like the meeting organisers to arrange both my flights and trains No travel arrangements required

Dates

Preferred departure date (dd/mm/yyyy)

This field is required

Preferred return date (dd/mm/yyyy)

This field is required

Flight Details

Preferred departure airport

This field is required

Preferred destination airport

This field is required

Frequent flyer numbers

This field is required

Name as it appears on your passport

This field is required

Date of birth (dd/mm/yyyy)

This field is required

Train Details

Preferred departure station

This field is required

Preferred destination station

This field is required

Preferences

Seat preference (aisle/window)

This field is required

Additional travel requirements

This field is required

Confirmed arrival date (dd/mm/yyyy)

This field is required

Confirmed arrival time

This field is required

Confirmed arrival flight number

This field is required

Confirmed departure date (dd/mm/yyyy)

This field is required

Confirmed departure time (dd/mm/yyyy)

This field is required

Confirmed departure flight number

This field is required

Please indicate if you would like to attend the arranged dinner(s)

Yes, I will attend the dinner(s)
No, I cannot attend the dinner(s)

Special dietary requirements (if applicable)

This field is required