YELLOW FEVER VACCINATION CENTRE (YFVC) CLASSROOM TRAINING (Limited availability for YFVCs) APPLICATION FORM *REQUIRED *Name of Applicant *Centre Name & Address (applicants not connected to a centre should provide their home address and specify): *UKYFVC NUMBER (YFVCs Only) Please state why you are applying for classroom training instead of online training as required *Postcode: *Telephone: *Training Status Have you or someone at your centre completed training previously? TRAINING ON BEHALF OF OTHER CENTRES List UKYFVC number(s) and/or centres (with full address) if this training will be completed on behalf of other YFVC(s) or centre(s): Yes/No (tick one) Applicant *Email *Job Title Alternative Contact Doctor/Nurse/Pharmacist only (excluding British Armed Forces) Indicate which training date you would like to attend *Choice 1: Date Location Date Choice 2: Location Special dietary / accessibility requirements: • • • • This form must be accompanied by the training application fee of £145. Places cannot be confirmed until payment is received. Returning this form with payment means that the applicant has read and agreed to the training special conditions. Payment is non refundable. Return forms and payment to: F PAYMENT BY CARD CREDIT CARD DEBIT CARD Yellow Fever Vaccination Centre Administration (Training) The National Travel Health Network and Centre UCLH NHS Foundation Trust rd 3 Floor Central S O LO ACCESS A M ER IC A N E X P R E SS S W ITC H / M A E S TR O V IS A D E LTA 250 Euston Road E LE C TR O N London NW1 2PG M A STE R C A R D F PAYMENT BY CHEQUE Make cheques payable to: UCL Hospitals NHS Foundation Trust C A R D N U M BE R __ __ __ __ __ __ __ __ __ __ __ __ __ (NO T A C CE PT E D BY M A IL O R D E R ) S EC U R ITY C O D E F PAYMENT BY BANK TRANSFER IS S U E N U M B E R *BACS payment confirmation slip required (forms will NOT be accepted without proof of payment) Name of Payee: University College London Hospitals NHS Foundation Trust Name of Bank: The Royal Bank of Scotland plc ___ ___ ___ (RE Q U IR ED ) ___ ___ E X PIR Y D ATE ___ ___ / ___ ___ V A LID FR O M ___ ___ / ___ ___ (R E Q U IR ED FO R SW ITC H /M AE ST RO P AY M EN TS ) N A M E A S O N C AR D (R EQ U IR E D ) __________________________________________ A D R E S S O F C AR D H O LD E R * __________________________________________ Branch Address: 62-63 Threadneedle Street, London EC2R 8LA __________________________________________ __________________________________________ Account Number: 23110914 Sort Code: 16 - 00 – 15 P O S T C O D E ___ ___ ___ ___ ___ ___ ___ Swift Code: RBOS GB2L TEL.N O . IBAN Ref: GB09 RBOS 1600 1523 1109 14 Reference ID: NATHNAC-YFT (S W ITC H ) ____________________________ R E C E IP T R E Q U IR E D * T H IS M U ST BE B ILL IN G A D D R E SS O F TH E C AR D H O LDE R