Short course application form 20092010 - Institute of Leadership
Short course application form 20092010 - Institute of Leadership
Short course application form 20092010 - Institute of Leadership
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RCSI <strong>Institute</strong> <strong>of</strong> <strong>Leadership</strong> Healthcare ManagementApplication Form Issue001Royal College <strong>of</strong> Surgeons in IrelandPr<strong>of</strong>essional Development Course Application Form***Completing Your Application Form***Please complete in BLOCK CAPITAL LETTERS using a BLACK pen.PERSONAL DETAILS:First Name:Surname:Course Name:Course Date:Address for ALL CorrespondenceAddress 1:Address 2:Address 3:Address 4:Tel:Mobile:Email:Present Appointment :Healthcare Organisation:Special Dietary Requirements:1 <strong>of</strong> 3
RCSI <strong>Institute</strong> <strong>of</strong> <strong>Leadership</strong> Healthcare ManagementApplication Form Issue001WHERE DID YOU HEAR ABOUT OUR PROGRAMMES?Website:Employer:Exhibition:Current/past student:Newspaper/Magazine (specify):Other (specify):COURSE PAYMENT:You may pay by: Cash (hand delivered to your local RCSI <strong>of</strong>fice only please DUBAI & BAHRAIN ONLY). Cheque (made payable to the Royal College <strong>of</strong> Surgeons please). Credit card (IRELAND ONLY, please complete details below).Name on Credit Card:Name <strong>of</strong> Applicant (if different):Card type:Card NumberExpiry Date:CVV Number (last 3 digits back <strong>of</strong> card):Amount to Debit:2 <strong>of</strong> 3
RCSI <strong>Institute</strong> <strong>of</strong> <strong>Leadership</strong> Healthcare ManagementApplication Form Issue001APPLICATION SUBMISSION DETAILS:Please submit to the RCSI-ILHM Centre where you will be registered:APPLICATIONS, (Bahrain) APPLICATIONS, (Dubai)<strong>Institute</strong> <strong>of</strong> <strong>Leadership</strong> & Healthcare Management, <strong>Institute</strong> <strong>of</strong> <strong>Leadership</strong> & Healthcare Management,Royal College <strong>of</strong> Surgeons in Ireland - Bahrain, Royal College <strong>of</strong> Surgeoans in Ireland - Dubai,PO Box 1550, 4th Floor A/P25,Busaiteen,KINGDOM OF BAHRAIN.Dubai Healthcare City, Dubai PO Box 505095,UNITED ARAB EMIRATES.Tel: + 973 17 351450 Ext. 2490Tel:+ 971 4 375 2116Fax: + 973 17 973 17 583600 Fax: + 971 4 429 8490Email: rattar@rcsi-mub.ieEmail:Website: www.rcsileadership.orgWebsite:mylinaraujo@rcsi.iewww.rcsileadership.orgAPPLICATIONS, (Ireland)<strong>Institute</strong> <strong>of</strong> <strong>Leadership</strong> & Healthcare Management,RCSI Reservoir House,Ballymoss Road,Sandyford,Dublin 18IRELANDTel:Fax:Email:Website:+353 (0)1 4028655+353 (0)1 2930431niamhcarroll@rcsi.iewww.rcsileadership.orgAPPLICATION SUBMISSION DETAILS:Please read the following before signing your Application Form:I certify that the in<strong>form</strong>ation on this <strong>application</strong> <strong>form</strong> is complete and accurate.Signature:Date:Please tick this box if you DO NOT wish to receive marketing in<strong>form</strong>ation from the RCSIPLEASE NOTE: All in<strong>form</strong>ation is kept confidential and used only for the purpose for which it was collected3 <strong>of</strong> 3
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