Individual Tutorial Application

HIRJI ASSOCIATES - Tutoring,Mentoring,Consulting & Coaching in Optometry

making optometric students more successful

Individual Tutorial Application Name ...................................................................................................................................................

Address................................................................................................................................................

Tel (H)...............................................Tel(W)........................................Tel(M)....................................

e-mail...................................................................................................................................................

Resits/Exams Scheduled at: UMIST/Cardiff/City/Bradford/Aston/Anglia/Glasgow Please Indicate

Date(s).....................................................................................................................

Subject(s) and Payment :

Mock/Virtual OSCEs (1 day) Tutorial 1 (min 3 students)	£850.00	cheque enclosed
Stage 2 Assessment (2 days) Tutorial 2	£1275.00	cheque enclosed
Contact Lenses (1 day) Tutorial 3	£850.00	cheque enclosed
Ocular Disease and Abnormality (1 day) Tutorial 4	£850.00	cheque enclosed
Routine Examination (1/2 day) Tutorial 5	£425.00	cheque enclosed
Binocular Vision (1/2 day) Tutorial 6	£425.00	cheque enclosed
Use of Drugs (1/2 day) Tutorial 7	£425.00	cheque enclosed
Vocational and Occupational Dispensing(1/2 day) Tutorial 8	£850.00	cheque enclosed
Low Vision (1/2 day) Tutorial 9	£425.00	cheque enclosed
CDM (1day) Tutorial 10	£850.00	cheque enclosed

Please tick to indicate and adjust for Group Discounts as follows:
2 delegates 25% 3-5 Delegates 50%; 6 to 9 Delegates 65%; 9 to 12 Delegates 75%

I understand that all tutorials are booked on a "first come first served" basis, that attendance at the tutorials does not guarantee success in the Final Assessment or OSCEs and that HIRJI Associates reserve the right to cancel these tutorials in part or in total.

Signed------------------------------------------------------------Date--------------------------------

Please make cheque payable to "N K Hirji",

You must print and post this application form
duly completed (with cheque(s)) to:
HIRJI Associates, 7 Milford Rd, Harborne, Birmingham
B17 9RL, UK

We will subsequently contact you to arrange the details.