<p> FRCPath Part 2 Mock Course 21st - 22nd February 2017 Dept of Clinical Biochemistry Royal Free London NHS Foundation Trust</p><p>Title: ______</p><p>First Name: ______</p><p>Surname: ______</p><p>Hospital: ______</p><p>Address: ______</p><p>Postcode: ______</p><p>Tel: ______Fax: ______</p><p>Email: ______</p><p>Please state dietary/ disability requirements: ______</p><p>I would like to attend (please encircle): 21st 22nd Both days</p><p>I would like to attend the above course and enclose a cheque of £75/ day (London Trainees) or £200/ day (Trainees within the UK, but training outside London). See below for mode of payment </p><p>Cancellation / Refund terms and conditions:</p><p>If you cannot attend the course please ensure you inform us 1 week prior to the course date. A £20.00 charge for administrative services will be applicable Closing date for registration is 10th February 2017 Modes of payment</p><p> Cheques are payable to : Royal Free Charity (Fund 17). Post your cheque to Dr. Nair, Department of Clinical Biochemistry, Royal Free Hospital, Pond Street, London, NW3 2QG. </p><p> Direct to the Charity’s bank account, details of which are set out below</p><p>Account Name: ROYAL FREE CHARITY </p><p>Bank name & address: LLOYDS Hampstead Branch 40 Rosslyn Hill London NW3 1NL</p><p>Bank sort code 30-93-80 Bank account number 00279476 Account Currency GBP IBAN GB39 LOYD 3093 8000 2794 76 BIC LOYDGB21065</p><p>In all cases please quote the FUND 17 as a reference when making payment. Please email [email protected] and [email protected] after making the payment. </p><p>Royal Free Charity (Fund 17)</p><p>Post cheques to Dr Devi Nair, Dept of Clinical Biochemistry, Royal Free London NHS Foundation Trust, London NW3 2QG</p><p>&</p><p>Email [email protected] and [email protected] </p>