Application Form. Sunday 15th. - Friday 20th. January 2017.

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North West MRCOG Part 2 Written Course.

 

Please Print !!!!!!!

 

Surname:        ...................................... First Names:     ..........................................

           

Preferred first name for name badges etc. ........................................................

 

Mailing Address: ....................................................................................................

 

...........................................................................................Post Code: ....................  

 

Work Phone: .........................................  Home Phone:..........................................

 

 Phone:  ........................................ E-Mail: ................. @ .....................

  

Have you worked in O&G in the UK?     Yes  /   No.

 

If "yes", for how long?    ........ years  ............. months

 

Have you sat the part 2 MRCOG exam before?  Yes / No.   If "yes", how many times .......... 

 

I enclose my cheque for 650 GBPounds / deposit (non-returnable) for 150 GBPounds.

Please make cheque payable to: NW MRCOG Course.

 

Please indicate how you heard about the course.

 

Consultant / colleague / NW Trainees' website / Specialty Tutor / RCOG website / Google / other search engine.

 

Other:  Please detail.  .......................................................................................................

 

Are you vegetarian ?   YES /  NO.

Do you eat fish?            YES / NO

Karen, the caterer uses only Halal meats.

Post to: Valerie M. McFarlane, 22 Lyndhurst Road, Didsbury, Manchester. M20 6AA.

Phone:  0161 434 2365.

Mobile:  07770893006.

 

 

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