HIRJI ASSOCIATES - Mentoring,Consulting & Coaching in Optometry

making optometric students more successful

*Name...........................................................................................................................................*GOC No: SO-.................................

*Address...............................................................................................................................................................................................

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

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

Dietary requests.....non-vegetarian/vegetarian/other.................................................................................................................................................. (Please indicate)

Please reserve me a place on the Revision Tutorials & Preparation for the College of Optometrists Stage 2 and OSCEs Course to be held at the  Education Resource Centre, Birmingham Women's Hospital, Metchley Park Road, Edgbaston, Birmingham B15 2TG. Tel 0121 623 6923. on the following dates:

 Course Dates: 28th,29th and 30th March 2011  []

6th,7th and 8th June 2011  []

Please tick one only
Overnight accommodation should be arranged directly with local hotels.
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  OSCEs and that HIRJI Associates reserve the right to cancel these tutorials in part or in total.

 [] I enclose a cheque for £660

*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

You will get a response by e-mail to confirm your place on the tutorials or otherwise.

*This information must be provided to be considered for these revision tutorials