BSS Dublin Application Form - Royal College of Surgeons in Ireland

Course Date:
st
nd
21 /22 January 2015
nd
rd
2 / 3 September 2015
Please tick course you would like to apply for:
PRINT NAME AS TO APPEAR ON CERTIFICATE ………………………………………………………………………
First name: ..….........................................................................................................................................................
Surname: ..........................................................…………………....Known as: ........................................................
Address for correspondence: ...................................................................................................................................
...................................................................................................................................................................................
Nationality: ..............................Mobile phone no: ......................................Email: ………………………………………
Specialty: .............................…Hospital: …………………………………… Grade: ………………………………………
Are you on the RCSI Basic Surgical Training (BST) Programme?
Yes
No
Irish Medical Council or GMC Number: .........................
(IMC Mandatory Requirement) :Fee €750.00 Please note payment must be submitted with your application
Enrolment: Cheques or Bank Drafts should be made payable to "Royal College of Surgeons in Ireland", or
alternatively you can enter your credit cards details below:
Card Types Accepted only: Visa / Visa Debit / MasterCard
Card Number:
- - - - / - - - - / - - - - / - - - - Exp Date: - - - - / - - - -
CVV Security No- - -
Signature of applicant: ...............................................................................Date: ......................................................
Cancellation:
A refund, less 20%, will be made if written notice of withdrawal is received by the
College at least one month prior to the course commencement date. No refunds will be made after this
date.
Completed application form, together with the full course fee and two passport-sized photographs, should be
returned to: BSS Course Administrator, Surgical Training Office, RCSI House, 121 St Stephen's Green, Dublin 2.
Telephone 00 353 1 402 8642 Fax 402 2459 email [email protected] Please attach 2 passport sized photographs
For office use only
Amount paid (cash/cheque/draft/ c card) €uro/STG£:
Received by: …………………… Date: ………………
Comments:
…………………………………………………….

Download Report