Apply

HIV and Hepatitis Resistance and Pharmacology Workshops 2021

Venue: The Jury’s Inn Hotel, Birmingham

You may use the below form to register your interest in attending one of our upcoming workshops. If you require further information, email our course organiser, Fiona Wilson, using this form.

Your application form will be acknowledged via email whichever method of submission you choose. Thank you.

Honorific:

Full name:

Job Title:

Grade:

Hospital Name:

Hospital Address:

City:

Post Code:

Your Email

Work Telephone:

Mobile Telephone:

Details of dietary requirements:


(Note that catering arrangements will be made based on the information that you have supplied on this application information. Please make us aware of any required changes to your dietary requirements at least 14 days prior to the course.)

I would like to be considered for a financially assisted place provided by an unrestricted educational grant provided by Gilead, VIIV, and MSD.
 Yes No

I have already been offered a sponsored place by (enter name of company/representative/contact):

Enter the email address of your sponsor or their representative, if applicable:

I wish to attend on the following dates: please TICK relevant box
 12/13 May 2020 9/10 June 2020 15/16 September 2020 13/14 October 2020