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					                                   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)                   □
                                                   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
Accepted payment options:

i) Electronic Bank Transfer:

Please complete an application form and email it to us at 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
                                          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
           Websites: and

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.

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