PRE COURSE REGISTATION OF INTEREST 2011 CERTIFICATE IN URODYNAMICS COURSE VENUE: (please mark 8 in box your preferred venue) Bristol Date TBC London Date TBC Bristol Date TBC London Date TBC Bristol Date TBC London Date TBC Manchester Date TBC Newcastle Date TBC Manchester Date TBC PERSONAL DETAILS: (please print) Title Special Interest (please tick) First Name Urology Last Name Obs & Gynae Job Title Other. Please specify : Hospital / Institution Full postal mailing address for correspondence Email: Tel: Mobile: Please state the amount of urodynamic experience you have below: <6mths >6mths- <1yr >1 yr Comments: I acknowledge there is an optional test at the end of the course and the full certificate is only issued to those achieving the pass mark. What are your aims in attending this course? Payment: There is no requirement to send payment, or invoice details now. We will contact you once the 2011 dates become available (probably around December). Please return this completed form to firstname.lastname@example.org or fax to 0117 323 8830 or by postal mail to the address below.