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Note: you will need details of a countersignatory to complete this form. If you do not have a countersignatory but would like to attend Conference, please email info@welshconservatives.com.

TitleFirst NameMiddle NameLast NameMaiden NameDate of BirthNationalityPlace of BirthPhone NumberEmail AddressMembership NumberAssociation

Address Line 1Address Line 2City/CountyPostcodeIf you are driving to The Pavilion Llangollen:Car MakeCar ModelCar Registration PlateIf you are attending the Gala Dinner or Supper:If you have a disability, please specify:Badge Details: please complete your details as you wish them to appear on your pass:Name on your passRepresenting constituency/areaCountersignature Details

This person cannot be a relative or spouse/partner. They must be able to confirm they have known you for a minimum of 6 months, that they are affiliated to the Conservative Party, and that the above information is correct. If you are unable to find a suitable countersignatory please contact The Welsh Conservative Party info@welshconservatives.com for assistance.

Countersignatory NameCountersignatory EmailCountersignatory – capacity knownCountersignatory – years knownCountersignatory – months known

The information you provide will be used solely for managing this Conference – you will not be added to a general marketing list, but will receive further details of the programme of events and other important Conference information. Data will be shared with the Police as part of security checks for the Conference. The organisers reserve the right to refuse admission without providing a reason, and if payment has been made it will be refunded in full. We are unable to refund accommodation costs, and so recommend you receive confirmation that your pass has been approved before booking a hotel, travel, or any other fixed expenses.

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