MERSEY COURSES |
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| Applicant Number (For Office Use Only) | ||||||||||||||||||||
| Course Reference: /________/__________ | ||||||||||||||||||||
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| Initials | ||||||||||||||||||||
| Home Address | ||||||||||||||||||||
| Postcode | ||||||||||||||||||||
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| Email address | ||||||||||||||||||||
| @ | ||||||||||||||||||||
| Hospital: | ||||||||||||||||||||
| Hospital contact # | ||||||||||||||||||||
| Cheque Details | Number: | Date | Amount | |||||||||||||||||
| Signature | ||||||||||||||||||||
| Proposed Date of Examination (Month & Year) | ||||||||||||||||||||
| Please ü Examining College | RCA | RCSI | ||||||||||||||||||
| Comments/Enquiries | ||||||||||||||||||||
| Date Application Dispatched | ||||||||||||||||||||
| Date Application Received | ||||||||||||||||||||
| Acknowledgement Dispatched | ||||||||||||||||||||
Please Print Clearly
Notes
Regarding Assignment of Cheques in Payment for Courses:-
Mersey Selective Course Cheque Payable To:- LHCH (MSA)
RCA Primary & Final MCQ Courses Cheque Payable To:- LHCH (MSA)
RCA Primary OSCE/Orals Course Cheque Payable To:- LHCH (MSA)
RCA Final (Booker ) Revision Course Cheque Payable To:- LHCH (MSA)
All Weekend Courses Cheques Payable To:- Aintree Hospitals NHS Trust
All Applications need be submitted to:
MSA Office Clinical Sciences Centre Aintree Hospitals Liverpool L9 7AL |