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Epidemiology for Clinicians 4th-6th January 2012 Application Form Title: Forename: Surname: Clinical Specialty – or other Discipline: Address: Phone: Mobile Phone: Email: Will you require parking? How did you hear about the course? Catering Requirements: Please indicate your catering requirements by ticking the appropriate boxes. Wednesday, Thursday, Friday, th th th 4 January 5 January 6 January Lunch Lunch Lunch Drinks Reception Drinks Reception Dinner Dinner Do you have any special requirements? Fees: Cost £ Paid £ Full Residential 300 Non-Residential 150 Payment in full should be made by cheque payable to: Medical Research Council th Refunds for cancellations will be payable up to 25 November 2011 (minus £50 administration fee), thereafter no refunds are possible. The application form plus full payment should be sent to: Mrs Julie Hands MRC Epidemiology Unit Institute of Metabolic Science Box 285, Addenbrooke’s Hospital Hills Road, Cambridge CB2 0QQ th Deadline: 30 September 2011 Data Protection Notice: The organisers will not pass your contact details to others without your consent. Please note that your information will be used for the purpose of organising this event and your name and clinical speciality or discipline will be added to the list of participants which will be distributed at the event.
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