Workshop Booking Form The Endgame Tobacco Control Workshop

Workshop Booking Form The Endgame: Tobacco Control Workshop 5 -6 June 2014, Riddel Hall, Belfast 9 -10 June, The Gibson Hotel, Dublin The Workshops are free but places will be limited to 30, so please book early to secure your place! Please complete all details in BLOCK capitals. Photocopy this form for each individual attending. Please tick clearly the Workshop you wish to attend: Belfast Workshop Dublin Workshop Title (Mr, Mrs, Ms, Dr) ________________________ First name ___________ Surname______________ Job title ______________________________ Organisation ____________________________ Work address _____________________________________________________________Postcode ___________ Work telephone number _______________________ Email address ____________________________ Please specify any special dietary or access requirements ____________________________________________ Confirmation and further information will be sent to you prior to the event. All cancellations must be made in writing and sent to IPH by email. Accommodation is not included but a list of nearby hotels can be provided on request. Completed forms must be returned by Friday, 16 May 2014 to: Sharon Brennan, Institute of Public Health, Forestview, Purdy’s Lane, Belfast BT 8 7 AR. Email: sharon. brennan@publichealth. ie Telephone: 028 90 690051