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  • Specialty Courses: Lister Application Form

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    Ahmad Shakir
    22 Ansichten2 Seiten
    This document is an application form for specialty courses provided by Lister. It requests information such as the applicant's personal details, contact information, preferred payment method, and signature accepting the terms and conditions. The form is used to register for multiple courses offered on different dates, including an MRCS Part B Tutorials course. It collects required fields like name, date of birth, and signature as well as optional fields like department and how the applicant heard about the course. Payment can be made by cheque, credit card, or invoice. Upon completion, the form is to be returned to Lister with the necessary payment details.

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    Datta's Course Appl

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    Datta's Course Appl

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    This document is an application form for specialty courses provided by Lister. It requests information such as the applicant's personal details, contact information, preferred payment method, and signature accepting the terms and conditions. The form is used to register for multiple courses offered on different dates, including an MRCS Part B Tutorials course. It collects required fields like name, date of birth, and signature as well as optional fields like department and how the applicant heard about the course. Payment can be made by cheque, credit card, or invoice. Upon completion, the form is to be returned to Lister with the necessary payment details.

    Copyright:

    © All Rights Reserved
    Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    22 Ansichten2 Seiten

    Specialty Courses: Lister Application Form

    Hochgeladen von

    Ahmad Shakir
    This document is an application form for specialty courses provided by Lister. It requests information such as the applicant's personal details, contact information, preferred payment method, and signature accepting the terms and conditions. The form is used to register for multiple courses offered on different dates, including an MRCS Part B Tutorials course. It collects required fields like name, date of birth, and signature as well as optional fields like department and how the applicant heard about the course. Payment can be made by cheque, credit card, or invoice. Upon completion, the form is to be returned to Lister with the necessary payment details.

    Copyright:

    © All Rights Reserved
    Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    von 2

    LISTER APPLICATION FORM

    Please
    photocopy as
    needed using
    one form per
    course

    SPECIALTY COURSES
    Please write clearly using BLOCK CAPITALS. All fields marked with * MUST be completed

    1. Course details
    12.01.07 14.01.07
    19.01.07 21.01.07
    26.01.07 28.01.07

    * COURSE NAME MRCS Part B Tutorials


    Where did you hear about this course:
    BMJ
    Brochure
    Flyer

    Website

    Word of Mouth

    Others _____________

    2. Your personal details


    * TITLE DR

    * FORENAME ALI

    * SURNAME TAGHI

    * DATE OF BIRTH /__ __ /__ __ / 1 9 __ __

    DEPARTMENT
    RETAINEE (South East Scotland region only) SESSIONAL GP

    PRESENT GRADE
    SPECIAL REQUIREMENTS
    3. * Your mailing address details

    All correspondence will be sent to your mailing address


    TEL
    FAX
    MOBILE

    POST CODE

    E-MAIL
    If you wish to receive information on other Lister training courses tick here

    4. * Your method of payment

    400 (350)

    COURSE FEE

    CHEQUE ENCLOSED (made payable to NHS Education for Scotland)


    x Please attach cheque here
    INVOICE Please see over for Terms & Conditions)
    CONFIRMATION MUST BE ATTACHED

    NAME/ORGANISATION
    ADDRESS

    A 2% administration charge is
    added to VISA and MASTERCARD

    VISA

    POSTCODE

    MASTERCARD

    CREDIT CARD NO /

    EXPIRY DATE /__ __/__ __/


    5. * Your signature

    MAESTRO/DELTA
    /

    Maestro/Delta Only:

    / EXPIRY DATE /__ __/__ __/

    ISSUE DATE /__ __/__ __/

    ISSUE NO_______________

    All unsigned application forms will be returned. For cancellation policies, terms and
    conditions, please refer to the information overleaf or www.nes.scot.nhs.uk

    I have read and accept the Lister terms and conditions: Signature..
    Please return this form to The Lister, 11 Hill Square, Edinburgh EH8 9DR. Fax 0131 651 4017
    FOR OFFICE USE ONLY
    COURSE CODE
    CO- ORDINATOR:

    CHEQUE ENC

    GO ON CBS

    YES NO
    YES NO

    ENTERED ON (DATE):
    CR CD/INVOICE:

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