Single Registration
Form Name
Name
*
First Name
Last Name
E-mail
*
Institution
*
Phone Number
*
-
Area Code
Phone Number
Are you a member of the Irish Thoracic Society?
*
Yes
No
Member
*
Consultant
SpR/NCHD
HSCP
Membership Number
*
Non-Member
*
Non-Member Consultant
Non-Member SpR/NCHD
Non-Member HSCP
Friday Lunch
*
Yes
No
Saturday Lunch
*
Yes
No
Will you be able to attend the Case Study Forum on Thursday night?
*
Yes
No
Would you like to attend Friday Gala Dinner?
*
Yes
No
Would you like to attend Friday Gala Dinner? (Non Consultant Members)
*
Yes
No
Do you have dietary restrictions?
Yes
No
Dietary Restrictions
Total
Would you like to receive CPD Certificate (with the condition of attendance)?
*
Yes
No
GDPR Agreement
*
I consent to having this web site store my submitted information so they can respond to my enquiry
Consent
*
I give permission to the organisers to contact me about future Irish Thoracic Society events
Payment
Total Amount
*
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Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please verify that you are human
*
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