North West MRCOG Part 2 Written Course.

Monday 17th. - Saturday 22nd. January 2011.

Please Print !!!!!!!

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

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

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

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

Mobile 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 £600 / deposit (non-returnable) for £100.

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.

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

Phone:  0161 434 2365.

Mobile:  07770893006.