UCL INSTITUTE OF NEUROLOGY

QUEEN SQUARE
THE NATIONAL HOSPITAL FOR NEUROLOGY AND
NEUROSURGERY
QUEEN SQUARE
LONDON WC1N 3BG

UCL Institute of Neurology National Hospital for Neurology & Neurosurgery Queen Square London WC1N 3BG
+44 (0)20 7692 2362 Fax:+44 (0)20 7278 5069 http://www.ucl.ac.uk/ion/
Director: Professor Michael G Hanna BSc(Hons) MBChB(Hons) MD FRCP(UK)
Institute Secretary: R P Walker BSc (Econ)
The Institute of Neurology promotes teaching and research of the highest quality in neurology and the neurosciences.

Education Unit

Direct line: 020 3448 4460

Email: jean.reynolds@ucl.ac.uk
UCL INSTITUTE OF NEUROLOGY
in association with The National Hospital for Neurology
and Neurosurgery
Application Form
Neurology 2015: leading edge neurology for the practising clinician
Please complete and return this form
Email: jean.reynolds@ucl.ac.uk
PLEASE WRITE IN CAPITAL LETTERS
Title: Professor/Dr/Mr/Mrs/Miss/Ms (delete as appropriate)
Surname

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Please state dates you will be attending:

Wednesday 25th March
2015 (half day)
YES / NO
(delete as appropriate)
(venue Wolfson Lecture
Theatre, NHNN)
Thursday 26th March
YES / NO
Friday 27th March 2015
YES / NO
(venue Logan Hall,

2015

Institute of Education)
Dietary requirements: please specify: ie gluten free

.
Course Fees:
Consultant and associate specialists: 190 for two days OR 140 per day
Clinical trainees and research fellows: 130 for two days OR 80 per day; 50 for half day on Wednesday only
Payment via online booking must be made before your place is confirmed:
http://onlinestore.ucl.ac.uk/browse/department.asp?compid=1&modid=2&deptid=36
Total number of days booked:.

Total price for bookings: ...