Application form to be printed out and posted to:
Mr. Fausto Palazzo MS FRCS
Dept Endocrine Surgery
Hammersmith Hospital
London W12 0HS
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Surname: _____________________________________________

First Name: _____________________________________________

Address: _____________________________________________





Telephone (work)_____________________________________________

Telephone (home)_____________________________________________

e-mail address _____________________________________________

I will / will not be having lunch. I am / am not vegitarian.

Course fee 95 (Consultants) / 25 (trainees) enclosed. Please make cheques payable to "Endocrine Surgery Research Fund", and write the name and address of the candidate on the reverse of the cheque. Note: Deadline for receipt of applications: November 27th. Bookings cannot be made without receipt of a supporting cheque

Course fee after November 27th: 105 (consultants) / 35 (trainees).