X hits on this document

PDF document

Friday 19 September 2008 - page 6 / 8

16 views

0 shares

0 downloads

0 comments

6 / 8

Register on-line today at www.rcog.org.uk/meetings

REGISTRATION FORM

Registration Fee

£185 (£157.45 + VAT) on or before 25/07/08

(Please tick as appropriate)

£235 (£200.00 + VAT) after 25/07/08

Psychiatric Disease in Pregnancy Friday 19 September 2008

Please read the section on General Information and Terms and Conditions on the rear of this brochure before completing this form

M9508

I agree to the terms and conditions on the back of this brochure (please tick this box)

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

PERSONAL DETAILS Title (Prof/Mr/Mrs/Ms/Dr/etc) _______________________________________________________

Surname ___________________________________________________________________________

Forename(s) ________________________________________________________________________

Sex M F

RCOG Registration No. (if applicable)

FRCOG

MRCOG

DRCOG

Retired Fellow/Member Other

Post _______________________________________________________________________________

Department

________________________________________________________________________

Hospital ___________________________________________________________________________

Address for correspondence

__________________________________________________________

(BLOCK CAPITALS PLEASE)

Town _____________________________________________________________________________

County __________________________ Postcode

________________________________________

Country (if not UK) ________________________________________________________________

Is this your work address?

yes

no

I do not wish my hospital details to appear on the list of participants to be circulated at the conference

continued overleaf

Document info
Document views16
Page views16
Page last viewedSat Dec 03 12:10:23 UTC 2016
Pages8
Paragraphs198
Words1794

Comments