MRCOG PART 1 COURSE “FORREST COURSE-ORGANISERS OF THE WHIPPS CROSS COURSE†MELAKA MANIPAL MEDICAL COLLEGE (26th NOVEMBER- 28th NOVEMBER 2010) PERSONAL DETAILS FULL NAME …………………………………………………………………………………………….. (Block Letters) POSTAL ADDRESS …………………………………………………………………………………….. ……………………………………………………………………………………………………………. EMAIL ADDRESS ……………………………………………………………………............................ NATIONALITY………………………………… DATE OF BIRTH ……………………. MALE / FEMALE TELEPHONE NUMBER (Work) …………………………. (Home)………………………………… ACADEMIC DETAILS University and Medical School…………………………………………………………………………… …………………………………………………………………………………………….......................... Degrees, Diplomas and Academic Distinction …………………………………………………………... ……………………………………………………………………………………………………………. Date of passing basic degree ………………………………………………………………………………. When are you taking Part 1 ………………………………………………………………………………. Dates of previous attempts at Part 1 ……………………………………………………………………… *COURSE FEES: RM 1000 / USD 325 *Hostel Accommodation(within Campus) : RM 40 / USD 20 per day *Cheques and Bank drafts are payable to PERTUBUHAN PENDIDIKAN PERUBATAN LEPASAN IJAZAH HOSPITAL MELAKA ➢ This application form should be accompanied with a cheque or bank draft payable to Pertubuhan Pendidikan Perubatan Lepasan Ijazah Hospital Melaka, please do NOT send cash. ➢ If you require hostel accommodation then please state check in and check out dates and include payment for the accommodation with course fees. Check in date:......./DEC/.2010. Check out date:…...../DEC/2010. TOTAL NIGHTS STAY:.............days Cancellation Policy ➢ A 90% refund will be made for cancellations received more than 6 weeks prior to the course ➢ NO refunds for cancellations received less than 6 weeks before the course ➢ Should this course not be held for any unforeseen circumstances the organizers of this course will NOT be held responsible, and participants will be fully refunded. Signature…………………………………. Date…………………………………… SEND COMPLETED APPLICATIONS TO: Course Secretariat : Attn : Miss Angeshwary MELAKA – MANIPAL MEDICAL COLLEGE Jalan Batu Hampar , Bukit Baru , 75150 Melaka. Malaysia ….......................................................................................................................................................................... For office use: Complete application form Bank draft or cheque received Hostel accommodation payment
