To apply for a place on this workshop please complete the application form and
tell us your reasons in a maximum of 200 words.
Notification of the outcome of applications will be sent by email within 2
weeks.
To confirm their place, successful applicants will then be required to pay the
registration fee (£100) via the conference website. Detailed information about
this process will be given in the confirmation email.
Please complete your details below.
All fields marked with an * are compulsory.
Please use only standard keyboard characters whilst completing this form.
|
*Title: |
|
|
*First Name: |
* Please enter your first name
|
|
*Surname: |
* Please enter your surname
|
|
|
* Please use normal characters
|
|
Degree/Qualification |
MD / PhD /
Other (if relevant) |
|
*Job Title: |
* Please enter your job title
|
|
*Institution |
* Please enter an institution
|
|
*Speciality |
* Please enter a speciality
|
|
*Address: |
* Please enter an address
|
|
|
|
|
|
|
|
*Town/City: |
* Please enter a town/city
|
|
County: |
|
|
*Postcode: |
* Please enter a postcode
|
|
*Country |
*Please select a country
|
*Telephone:
(inc. int. code) |
Please enter a valid number (Numbers/spaces only)
|
|
|
Please enter a phone number
|
|
|
|
|
*Email: |
* Please enter an email address
|
|
|
* Please enter a correct email address
|
|
*Confirm Email: |
* Please confirm your email
|
|
|
Please check the email addresses match
|
|
|
|