National Centre for Pharmacoeconomics,

St James’s Hospital, Dublin 8

Ph: 01 4103427 fax: 01 4730596 email: info@ncpe.ie

BOOKING FORM

Course Reference: 2015/04

Surname:	_______________________________________

Forename:	_______________________________________

Title (Dr/Mr/Ms/Mrs):	_______________________________________

Technical qualification:	_______________________________________

Job title:	_______________________________________

Organisation:	_______________________________________

Address:	_______________________________________

_______________________________________

Daytime Telephone No:	_______________________________________

Fax No:	_______________________________________

E-mail address:	_______________________________________

Signature:	_______________________________________

Date:	_______________________________________

COST OF COURSE €495.00 (INCLUDES COURSE MATERIALS, LUNCH & COFFEE BREAKS)

Payment by cheque/bankers draft to be made payable to “The Haughton Institute”. Visa card accepted only but please note there is a service charge of 2.5%. Bank transfers also accepted please contact the centre for details. *Please use NCPE invoice number or your company name/your own name as a reference with all bank transfers, cheques and drafts, this is important for tracing.

Note: Confirmation of place on the course is not guaranteed until payment is received.

ACADEMIC STUDENT DISCOUNTS AVAILABLE, GROUP DISCOUNTS AVAILABLE ONLY ON MULTIPLE BOOKINGS *only at time of first booking – contact Centre for details.

All participants who complete the course will receive a certificate of attendance.

MAILING LIST DETAILS

I wish to be added to your mailing list	__

My mailing details are as outlined above	__ or as detailed below:

Address:	______________________________

______________________________

E-mail address:	______________________________

Visit our webpage at www.ncpe.ie for further information about the National Centre for Pharmacoeconomics.