Stroke Thrombolysis & Clot Retrieval Workshop Registration Form, The Stroke Network

Stroke Thrombolysis & Clot Retrieval Workshop

Tuesday 26th March 2019

10am - 4pm

Trustpower Baypark Arena, Mount Maunganui

Registration Form

Name:

Organization/DHB:

Role:

Address:

Email:

Contact Phone:

Dietary Requirements:

Gluten Free Dairy Free Vegetarian Vegan

Payment:

Medical Staff @ $80 incl GST Nursing Staff @ $40 incl GST

Payment Details:

Direct credit BNZ account number: 02-12690023111-00 Cheque to: Stroke Foundation of NZ, PO Box 12-482, Thorndon, Wellington 6144 Credit Card: to make a credit card payment please call Monique on 0800 787 653

&nsbp;

Please include SURNAME in particulars box and THROM3 in reference box if paying by direct credit

Do you require an invoice for payment?:

&nsbp;

Please include name and email if different from registrant above