UK-APPLICATION FORM for Fellowship of Interventional Pain Practice

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REGISTRATION INFORMATION PLEASE MAIL APPLICATION TO: Dr Charles A. Gauci MD FRCA FIPP WIP FIPP Examination UK Chapter The Margaret Centre Whipps Cross University Hospital Whipps Cross Road Leytonstone E11 1NR
All exam fees must be paid in $US and in no other currency Please tick method of payment enclosed Check___; Money Order___; Cashier Check___; Bank Transfer ___; Credit Card ___; Other ___ Total Due: $2000.00 Final deadline Dec.1, 2005 Review Course ($500) is March 11, 2006 and registration forms will be provided by ASIPP. IF OTHER PARTY WILL PAY THE FEE, give name, address and phone of authority that will pay __________________________________________________________________ IF USING BANK TRANSFER, give name and location of your bank: __________________________________________________________________ Transfer your bank funds to American State Bank • 1401 Avenue Q • Lubbock, Texas 79401 USA • Routing Number: # 111322583 • Account Name: World Institute of Pain • Account Number: 10064890 • Attention: Thelma, Account Manager IF PAYING BY CREDIT CARD, check one: _Visa; _____ Master Card (American Express not accepted) Number of Account__________________________________________________ Expiration Date: ___________________________________________________ Signature on Account: ______________________________________________
Page 1 and 2: Section of Pain Practice UK-APPLICA
Page 3 and 4: Your professional practice setting
Page 5 and 6: Recommendations Indicate in the spa
Page 7 and 8: I understand that I must keep my li
Page 9: REQUIREMENT OF Ethical And Professi

UK-APPLICATION FORM for Fellowship of Interventional Pain Practice

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