Heart Rhythm Congress 2011

Please indicate if you are a member of Arrhythmia Alliance or Heart Rhythm UK. If you are not a member of either, please leave the box unticked.

1. Please indicate if you are a member of Arrhythmia Alliance
   Member of A-A
2. Please indicate if you are a member of HRUK
   Member of HRUK
3. HRUK Membership Number

Please check this box if you are attending as an Abstract Presenter

1. Please indicate if you are an Abstract Presenter
   Are you an Abstract Presenter

Please check this box if you are attending as Invited Faculty

1. Please indicate if you are Invited Faculty
   Are you Invited Faculty

Please check this box if you are attending as a patient or carer

1. Please indicate if you are a patient or carer
   Are you Patient/Carer

1. Occupation Please select... Nurse Physiologist General Practitioner Consultant Clinical Researcher Education Student Trainee/Registrar Industry Charity Worker Administrator Other - please specify
2. Occupation - other
3. Speciality Please select... Clinical Cardiology Electrophysiology Paediatrics Geriatrics Heart Failure Surgery Other - please specify
4. Speciality - other

1. Workplace Please select... GP Practice Private Practice Hospital Clinic Industry Academic Institution Government Patient Group Other - please specify
2. Workplace - other
3. How did you find out about HRC* Please select... Email bulletin Journal advertisement From a colleague HRC website Previously attended HRC Other - please specify
4. How - other