Evidence Based Practice Nursing
School of Community and Health Sciences
Application Form for Study Day/Short Course
Self Funding, Employer Funded and Non NHS London Trust Sponsored 1. Study Day(s)/Short Course(s) Information
Course Ref No 1 2 3 Course Title Preferred Date* Please complete this form using black ink, write neatly and clearly in order for us to process it promptly. All sections must be completed.
NM S002
Venepuncture and Cannulation
*We will endeavour to provide a place on the requested date. Should this not be possible, you will be offered an alternative date. Please note: If you are Self Funding please tick this box o
2. Personal Information Title Ms Mr/Miss/Mrs/Ms/Dr/Other .................. Previous Name(s) (if changed) First Name
Margaret
Surname
Boyle
Date of Birth
Student Number (if Known)
D D/M M/Y Y Y Y 13/03/1965
Home Address ........................................................................... 23 Walford Road .................................................................................................
London .................................................................................................
Tel No. (Home) Tel No. (Work) Tel No. (Mobile)
020 7254 8179 ........................................................................ 020 8525 6047 ......................................... Ext .................... 07957242 308 ........................................................................
................................................................................................. N18 8EF ................................................... Postcode ........................... 3. Present or Most Recent Employment Post Held Speciality Speciality
Clinical Nurse Specialist
Personal/Work Email Address m.boyle@stjh.org.uk
Palliative Care
NMC PIN (if registered nurse, midwife or health visitor) 83k0528s Name of Hospital/Practice
St Joseph's Hospice
NMC PIN Expiry Date
D D/M2011 Y Y Y 01 01 M/Y
Application Form for Study Day/Short Course
Self Funding, Employer Funded and Non NHS London Trust Sponsored 1. Study Day(s)/Short Course(s) Information
Course Ref No 1 2 3 Course Title Preferred Date* Please complete this form using black ink, write neatly and clearly in order for us to process it promptly. All sections must be completed.
NM S002
Venepuncture and Cannulation
*We will endeavour to provide a place on the requested date. Should this not be possible, you will be offered an alternative date. Please note: If you are Self Funding please tick this box o
2. Personal Information Title Ms Mr/Miss/Mrs/Ms/Dr/Other .................. Previous Name(s) (if changed) First Name
Margaret
Surname
Boyle
Date of Birth
Student Number (if Known)
D D/M M/Y Y Y Y 13/03/1965
Home Address ........................................................................... 23 Walford Road .................................................................................................
London .................................................................................................
Tel No. (Home) Tel No. (Work) Tel No. (Mobile)
020 7254 8179 ........................................................................ 020 8525 6047 ......................................... Ext .................... 07957242 308 ........................................................................
................................................................................................. N18 8EF ................................................... Postcode ........................... 3. Present or Most Recent Employment Post Held Speciality Speciality
Clinical Nurse Specialist
Personal/Work Email Address m.boyle@stjh.org.uk
Palliative Care
NMC PIN (if registered nurse, midwife or health visitor) 83k0528s Name of Hospital/Practice
St Joseph's Hospice
NMC PIN Expiry Date
D D/M2011 Y Y Y 01 01 M/Y