Essential Surgical &
Course for Medical
April 11, 2013
Please complete all sections of the application form in BLOCK CAPITALS. Post or email completed application to the ICENI Centre
(address details shown at the bottom of the form).
Home Address (including postcode)
Year Interested in Surgery Y N
Do you have any special dietary requirements? Y N
If YES, please give details
Do you require information about local accommodation? Y N
Please note that your fee does NOT cover accommodation and we are unable to make accommodation
arrangements on your behalf.
For marketing purposes, please tell us where you heard about this course.
ICENI website Mailing Recommendation
Have you completed the RCS Basic Surgical Skills Course? Yes No
Course Fee : £35 The course fee includes all course materials, tuition, and refreshments throughout the
Method of Payment:
By cheque Tick the box and enclose a cheque made payable to:
Colchester Hospital University NHS Foundation Trust
By credit/debit card Please contact our finance department on 01206 742647 and quote
Essential Skills Course fee budget code S100 056
16 places are available on the course – they will be allocated in order of receipt of application with
Please note the course your fee is not refundable.
Whilst we make every effort to run courses as advertised, we reserve the right to change the timetable
and/or the teaching staff without prior notice and to cancel any courses without liability (in which case there
will be a full refund of course fees to the participant).
Please return this form via post or e-mail to:-
ICENI Centre Co-ordinator
Colchester General Hospital
Essex CO4 5JL
Tel. 01245 686791 or 07500 993305