Irish Society of Obstetric Anaesthesia (ISOA) Friday 6 th December
PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS USING BLACK INK
This form should be returned to:
Catherine Finn, Department of Anaesthesia, Rotunda Hospital, Parnell Square, Dublin, 1.
Telephone: 01- 8171794 Fax: 01- 8730347 Email: cfinn:rotunda.ie
Name of meeting:
Pre-Registration Fee:
Irish Society of Obstetric Anaesthesia (ISOA) Friday 6 th December, 2013.
On-Site Registration Fee:
€100
€130
Concurrent Echo Workshop €50
Surname:
Address line 1:
Address line 2:
Forename 1:
Address line 3:
Town/City: Country:
Current Hospital: _________________________________________ Training Post Number: _________________________________
Telephone number:
Email address:
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FINANCE DEPARTMENT
College of Anaesthetists of Ireland, 22 Merrion Square North, Dublin 2
Name of meeting:
Irish Society of Obstetric Anaesthesia (ISOA) Friday 6 th December, 2013.
Surname: Forename 1:
Payment can be made by Euro cheque, made payable to The College of Anaesthetists of Ireland, or by credit card below:
Please charge my credit card: Visa MasterCard Total Remittance:
Card number: - - - Expiry Date
Security Code: (last three numbers on back of credit card)
Date:
Cardholder's signature: Cardholder's name:
