Atls crse app form
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Royal College of Surgeons in Ireland Medical University of Bahrain Telephone: 00973 17351450 EXT 3065Facsimile: 00973 17330806/17330906Email: inizar@rcsi-mub.comAPPLICATION FORM for Basic surgical skills (bss) course
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
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