MRCOG (PART 11) THEORY COURSE

Whipps Cross University Hospital, NHS Trust

(Please type or complete in Block Letters)
Full Name (Surname)(First Names)...
Postal address.
.Post code...
Nationality...Date of birth..
Contact details: (Work/Home/Mob)..............................
Email address ...Male/Female
Academic details
University and Medical School..
Degrees, Diplomas and Academic Distinction..
Date of passing Part 1
When are you taking Part 2
Dates of previous attempts at Part 2..
Appointments
Present and Previous appointments:
Dates
Grade

Specialty

Hospital

PLEASE INCLUDE A PASSPORT SIZE PHOTO WITH APPLICATION FORM

Fees: 800:00 (refreshments and lunch included)
(PLEASE CALL 020 8535 6649 TO MAKE A CREDIT OR DEBIT CARD PAYMENT)
Please make cheque/bank draft payable to:
Whipps Cross University Hospital Medical Education and Research Trust
Cancellation Policy
A 90% refund will be given for cancellations received more than 6 weeks before the course
There will be no refunds for cancellations received less than 6 weeks before the course

Signature ..Date.

SEND COMPLETED APPLICATIONS TO:

Mrs. Heather Philip / Ms. Avelyn Hixon
Whipps Cross University Hospital

Medical Education Centre

Whipps Cross University Hospital
Leytonstone, E11 1NR
020 85356649 020 8539 5522 Ext: 5331
020 8535 6494
heather.philip@bartshealth.nhs.uk / Avelyn.Hixon@bartshealth.nhs.uk
FOR OFFICIAL USE: Date received..Refused..