HIRJI ASSOCIATES - Mentoring,Consulting & Coaching in Optometry

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Final Assessment Tutorial Application 2009

making optometric students more successful

Endorsed & Recommended by........ 

 

*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 Pre-Final Assessment tutorials 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:8th,9th and 10th June 2009 []; 3rd,4th and 5th August 2009  []

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  Final Assessment  and that HIRJI Associates reserve the right to cancel these tutorials in part or in total.

You may use PayPal to pay fees by Credit or Debit Cards   VisaMastercardPayPal CreditCardAmerican ExpressSwitchSoloVisa DeltaVisa Electron

 [] I have authorised payment of £752 including VAT (£112) by  

Course Dates
(please select if more than one course dates offered)

  OR
(preferred method)

 [] I enclose a cheque for £752 including VAT (£112)

 

*Signed------------------------------------------------------------*Date--------------------------------

If paying by cheque (preferred method) please make cheque payable to "N K Hirji",

Whether you pay by PayPal or Cheque you must print and post this application form 
duly completed (with cheque(s) if applicable) 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