INSIDER MEDICAL Medical School Courses APPLICATION FORM Please type or print. Surname Forenames Title GMC Number (if applicable) Home Address Work Address ST Level Specialty / Specialties Contact telephone number(s) *Email address (ESSENTIAL) Course Date (please select) th 30 October 2010 (Medical School Entry Course) □ th 30 October 2010 (Medical School Finals Course) □ Cheque Payment enclosed □ Medical School Entry Course £299 inc. VAT □ Cheques are made payable to: Insider Medical Ltd Medical School Finals Course £299 inc. VAT □ Please note, if eligible, the 17.5% VAT may be reclaimed from HMRC. We will provide a VAT receipt as evidence that VAT has been paid. Courses include a comprehensive course pack, lunch and all refreshments. Accepted payment options: i) Electronic Bank Transfer: Please complete an application form and email it to us at email@example.com. We will then provide you with the necessary details. ii) Cheques or Bankers Drafts: Please post your Completed Application with full Payment to: (Cheques made payable to: Insider Medical Ltd) Insider Medical Ltd 1A Christchurch Hill Hampstead London NW3 1JY Venue: London (Charing Cross Hospital) Your place on this Course will only be secure when your Application and Payment is received. Registration packs will then be posted. All Cheques must be received 7 days prior to the Course date, otherwise only cash will be accepted (at course registration). Please note post-dated cheques will not be accepted. Course Certificates and Receipts will be provided at the time of Course Completion. For further information, please contact Insider Medical: Telephone: 020 3524 5774 or 07886205399 Email: firstname.lastname@example.org Websites: www.insidermedical.co.uk and www.insidermedical.com Terms & Conditions: Please note there is a 10% administration charge for any cancellations up to 15 working days prior to the course. There is a 50% cancellation fee for any cancellations 5-15 working days prior to the course. Cancellations within 5 working days of the course are non-refundable.