1st International Radical Prostatectomy Summit

1 st International Radical Prostatectomy Summit

European Satelite meeting at King’s College Hospital, London

13 th – 15th March 2002

Name ________________________________________________________________________

Address ________________________________________________________________________

________________________________________________________________________

Telephone ______________________________ Fax_________________________________

Email __________________________________________

Payment can be accepted in sterling or Euros:

Resident in training: yes no (attach a confirmatory letter from your institution or trainer)

I wish to register for the meeting for 2 / 3 days

I will be present on: 13 th March 14th March 15th March Delete where applicable

I enclose a cheque for ______________ made payable to King’s College London

or

A Bank transfer for the sum of has been made to the account below.

National Westminster Bank PLC, 65 Aldwych, London WC2B 4EJ

Sort code 56-00-13 Account number 96707402

Account name MSS9750 Swift-Code NWB KGB2L

Signature ______________________________________ Date ________________________

Send your completed application form and payment to

Helen McFarland

Ethicon Endosurgery (professional education)

Simpsom Parkway

Kirton Campus

Livingston

West Lothian

EH54 7AT, UK

Tel: +44 (0)31 442 5621 Fax: +44 (0)1506 462606