Surgeon Programme

V/R Skills Study Day 2010

I would like to apply to attend the Alcon Education Programme on

Wednesday 16th June 2010

I understand that places are limited and, as such, no guarantee can be given at this stage that my application will be successful. I also appreciate that courses may have to be cancelled at short notice due to circumstances beyond Alcon's control.

Note Fields marked with * are Mandatory

* Title

Dr.

Mr.

Mrs.

Miss

Ms.

* First name

* Last name

*Status

* Hospital

* Address for Correspondence**

* Daytime Telephone Number:

* E-Mail address

Under the ABHI Code of Business Practice, Alcon is required to inform your superior, hospital administration or designated competent authority (as appropriate), offering them the opportunity to comment on, approve or oppose your attendance. Please indicate below to whom you would like us to direct this correspondence to.

* Title

Mr.

Mrs.

Ms.

Miss.

Dr.

Prof.

* Name

* Position

* Address for Correspondence**

* Approximately how many V/R operations have you performed ?

None

1 - 10

21 - 50

50 - 100

More than 100

Do you use 23G ?

Never

Occasionally

Almost Always

Do you use 25G ?

Never

Occasionally

Almost Always

What do you hope to gain from this course ?

** Please note that all information will be treated in the strictest confidence and the correspondence address will only be used in relation to the Alcon Study Day.