LRCTC Booking Form

London Regional Cytology Training Centre

London Regional Cytology Training Centre, Level 6X Room 006, St Marks Building, Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ. Telephone No 020 8869 5270. Fax No 020 8869 5094 Email: lrctc.booking@nwlh.nhs.uk

Please complete the application form below:

(For fields with a * symbol, an entry is required to submit the form)

Please enter course details:

Course Name *

Course Date *

Please enter personal information:

Surname *

Title

Forenames *

Date of Birth

Sex

Male Female

Hospital / Practice *

Street Address *

Address (cont.)

Post Code *

Correspondence Address *

Address (cont.)

Post Code *

Work Phone *

Home Phone

E-mail *

Position *

Special Dietary Requirements

Vegetarian None

( Sorry, we are unable to provide kosher, only vegetarian)

Do you require information about local accommodation? (Please note that your fees do NOT cover accommodation. Also check our "where to stay" section)

Yes No

Ethnic Origin

(Required for postive monitoring purposes only)

Other - please specify

Please enter Training Officer Details (Excludes sample taker training courses)

(Required for the Gynaecological Cytology Introductory Course)

Training Officer (name)

Telephone

Fax Number

E - Mail

Does the trainee have the necessary qualifications to attend this course?

Yes No

Invoicing details: (Excludes sample taker training courses)

The following GYNAECOLOGICAL COURSES are free in the LONDON REGION ONLY:

Introductory Course
Follow - Up Course
Pre Exam Course
Update Course

For all other courses and regions please see the course details page.

Please make your cheques payable to:
NPH TRUST FUND
If you are sending a cheque, please enclose a copy of this form.
OR
provide full invoicing details below.

CANCELLATION FEES:

2-4 weeks prior to course 50% will be deducted. 0-2 weeks prior to course no refund will be given.

Please enter invoicing details:

Hospital / Organisation:

Address:

Address (cont.)

Post Code

Budget Holder Name

Telephone