RSV-reg

Molecular detection of Respiratory Syncytial Virus (RSV) Registration Form

UK NEQAS for Microbiology

The registration is for the January 2020 distribution.

Notes for completing the Registration Form

Please fill in the details below as requested.

Participation ID: WR***

Title

Forename:*

Surname:*

Position (e.g. Head of laboratory):

Sub-Dept:

Department:

Organisation/Hospital:*

Correspondence address Street:

Town / City:

Country:

Postcode:

Telephone:

Fax:

Primary Email*

This would normally be your work email which we will use for all communications

Secondary Email

This should be a complete separate personal email address which we can use in case your primary email fails

Subscription:*

Molecular detection RSV (£234.40) including shipping

Declaration (to be signed by the Head of Laboratory or similar authority)

I wish to enrol in this scheme, which uses exclusively web-based access for submission of results and comments on the specimens in the scheme and access to reports, and have completed the details required. I am aware that there is a charge.I understand that a username and password will be issued to regulate access and that I am responsible for administering disclosure, access and changes of password.By checking the box next to ‘I agree to the declaration’, you are deemed to have signed the above declaration. Your application will not proceed unless you check the box.

I agree to the declaration*

A confirmation email of the information provided will be sent to your primary email address.

After submitting the form you will be directed to PayPal website to make the payment. Please use your PayPal login or use the PayPal Guest Checkout (to pay by debit/credit card).

Is someone else paying on your behalf?*

Yes

No

Payee Name:

First

Last

Payee E-mail:

Please enter the security code: