Application Form to begin course January 2010
Instructions (any difficulty please email info@bpna.org.uk or telephone 01204 492888):
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a) On your browser click ‘File’ and then ‘Save As’. Save this form to your computer.
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Save the file again as ‘File Name: your surname and initials’ and ‘File Type: Word Document’
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a) Complete the personal details section.
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Complete ‘Why you would like to do the BPNA distance learning course’ (100 word limit).
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Paste a copy of your cv on to the end of the form.
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Save the document.
3. Email the completed document as an attachment to: info@bpna.org.uk
4. Closing date for applications is 31 October 2009.
Personal Details:
Title: First Name: Surname:
Hospital employed at:
Deanery:
Address for correspondence:
Postcode:
Work Telephone: Home Telephone:
Mobile:
Email:
If Trainee, CCST Date: _______________ Are you in a National Grid Post? Yes / No
Why would you like to do the BPNA distance learning course?
Please write why you would like to do this course in no more than 100 words:
I would like to do the British Paediatric Neurology Association’s distance learning course because
Educational Supervisor:
I have read ‘Information for Educational Supervisors’ (www.bpna.org.uk/DL/infoedsup.pdf) and have agreed to be the applicant’s educational supervisor if they are offered a place on the distance learning course.
Title: First Name: Surname:
Position:
Address for correspondence:
Postcode:
Work Telephone:
Email:
Have you attended a distance learning Educational Supervisors’ training?
Curriculum Vitae
Applicant, please paste a copy of your CV here.
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