* Indicates a required field

Forename - As you wish it to appear on certificate*

Surname - As you wish it to appear on certificate*

Job title*
—Please choose an option—General PractitionerNurse (community)Nurse (acute)MicrobiologistID ConsultantConsultant microbiologistConsultant virologistPharmacist (acute)Pharmacist (community)TraineeStudentProfessorScientistMember of publicOther
IF other, please specify

Institution/Organisation*

Email address*

Postcode*

Country*
—Please choose an option—United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndaman and Nicobar IslandsAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanAzoresBahamasBahrainBalearic islandsBaliBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBorneoBosnia and HerzegovinaBotswanaBrazilBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurmaBurundiCabreraCambodiaCameroonCanadaCanary IslandsCape VerdeCayman IslandsCentral African RepublicChadChannel IslandsChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCorsicaCosta RicaCôte d’IvoireCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEaster IslandEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFormenteraFranceFrench GuianaFrench PolynesiaGabonGalapagos IslandsGambia, TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuyanaHaitiHawaiiHondurasHong KongHungaryIbizaIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau SARMacedoniaMadagascarMadeira IslandsMajorcaMalawiMalaysiaMaldivesMaliMaltaMargarita IslandMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMenorcaMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRepublic of Korea (S. Korea)ReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin/Sint MaartenSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTahitiTaiwanTajikistanTanzaniaThailandTibetTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands (British and USA)Wake Island and the US Pacific IslandsWallis and Futuna IslandsWestern SaharaYemenZambiaZanzibarZimbabwe

Which Event did you attend?*
—Please choose an option—North East - 11th OctoberSalisbury - 16th OctoberBirmingham - 17th OctoberCardiff - 18th OctoberEdinburgh - 28th OctoberNorth West - 5th NovemberLondon - 7th NovemberBelfast - 22nd NovemberLeeds - 22nd NovemberLondon - 10th December