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ROYAL COLLEGE OF SURGEONS IN IRELAND 123 St. Stephen’s Green, Dublin 2 APPLICATION FORM RCSI Cardiac Surgery Skills Course Intermediate Procedures (Valve Surgery) Friday 15th April 2011 Please note that places are strictly limited and will be allocated on a “first-come first-served” basis. All applications must be accompanied by a cheque or draft made payable to the “Royal College of Surgeons in Ireland” in the amount of € 300. Please complete in BLOCK LETTERS First name: ............................................................................ …………Surnames:……………………………………………... Known as: ..........................................................…………...................E-mail address:.........…….................................……...... Address for correspondence: ........................................................................................................................………………................….......... .........................................................................................................……………...........…........... Nationality: ....................................…….........Contact phone no: (home)……………............(mobile).........…..........…............ Irish Medical Council or GMC Number: ........................................................................................ ..……………...……............. Current Post: Hospital:....................................................…............................Ph:............…………….......…Bleep:… .......... Signature of applicant:.................................……………......................…...............Date:.............…………............................ Completed application form, together with the full fee if applicable and two passport-sized photographs, should be returned to: Orla Mockler, Cardiothoracic Surgery Course Coordinator, Surgical Training Office, Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2. Please note that places on this course will be reserved ONLY upon receipt of completed application and payment in full of the course fee. Please attach 2 passport sized photographs here For office use only Amount paid (cash/cheque/draft) €uro//STR£: ………………….. Received by: ……………………… Date: …………………. Comments: ……………………………………………………….
