Application Form.
| DRCOG page | The Stockport DRCOG Package |
The
Please
Print !!!!!!!
Surname: .......................................................... First Names: .....................................
Mailing
Address:
......................................................................................................
...........................................................................................Post
Code: ....................
Will you have done a job in O&G by the time of the exam? Yes / No.
If so, for how long? ..................months. Which hospital? ..............................................
Will you have done a course in family planning? Yes / No.
Work Phone: .........................................
Home Phone:..........................................
Mobile Phone: .....................................
I enclose my cheque for
£350, made payable to: “
(or
deposit £100….balance payable at the Course.)
To optimise how we advertise the course, it helps to know how you heard about it.
From a colleague who attended a previous course / Poster in the Hospital / Google / RCOG Web Page / Consultant / GP Tutor.
Other:
Please detail. ...................................................................................................
Are you vegetarian? Yes / No.
Post to: Dr. Tom McFarlane, 22 Lyndhurst Road, Didsbury, Manchester. M20 6AA.
Any problems: phone Valerie – 077 7089 3006.
Office: 0161 434
2365.
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