Application form



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Royal College of Surgeons in Ireland

Medical University of Bahrain

Telephone: 00973 17351450 EXT 3065
Facsimile: 00973 17330806/17330906
Email: inizar@rcsi-mub.com

APPLICATION FORM for Basic surgical skills (bss) course


Course Date: 18th Wednesday, 19th Thursday & 20th Friday March 2015


PRINT name as to appear on Certificate …………………………………………………………………………
First name:….............................................................................................................................................................
Surname: ..........................................................…………………....Known as: ...........................................................
Address for correspondence: .......................................................................................................................................
.......................................................................................................................................................................................
Nationality: ..............................Mobile phone no: ......................................Email: ……………………………………..
Specialty: .............................…Hospital: …………………………………… Grade: ……………………………………
Do you have a sponsor? Yes No

If so, please provide details: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………


Fee: BD300.000 – Please note payment must be submitted two weeks prior to course commencement.
Enrolment: The fees can be paid by electronic bank transfer as per details below. Please forward your proof of remittance to fees@rcsi-mub.com, and quote “Basic Surgical Skills (BSS) Course” when making payment.
Bank Name:             Ahli United Bank, Manama Branch

Bank Address:        128 Government Avenue, PO Box 5941

                     Manama, Kingdom of Bahrain



SWIFT CODE:          AUBBBHBM

Beneficiary Name: RCSI – Medical University of Bahrain

Account No:             0001-797799-001

IBAN:                        BH32 AUBB 0000 1797 7990 01

Signature of applicant: ...............................................................................Date: ......................................................
Cancellation: A refund, less 20%, will be made if written notice of withdrawal is received by the College at least two weeks prior to the course commencement date. No refunds will be made after this date.

Completed application form, together with two passport-sized photographs, should be returned to: Irfan Nizar, Royal College of Surgeons in Ireland – Medical University of Bahrain, P.O. Box 15503, Adliya, Kingdom of Bahrain. Please attach 2 passport sized photographs



For office use only













Amount paid BHD……………..

Received by: …………………… Date: …………………….

Comments: …………………………………………………….




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