Application form

Fields marked with * must be entered
Please circle relevant course date
Autumn course 2007/08 Spring course 2008
*Title
*Full Name
*DOB
*Correspondence Address
*E mail
*Phone
*Mobile
Education
University degree
Yes No
Medical (dental, veterinary) degree
Yes No
Biomedical Sciences degree
Yes No
*Describe University course (Years, University Name)
*Other relevant course(s)
*Seminars and short courses
*Certificate of Membership (state which registering body and forward photocopy of Certificate)
Medical experience
Doctor, dentist, veterinary surgeon
Yes No
Pharmacist, biochemistn
Yes No
Osteopaths, chiropractors
Yes No
Naturopath, complementary medicine
Yes No
Biomedical research (including postgraduate courses)
Yes No
Psychologist, psychotherapist
Yes No
*Medical Speciality
*Royal College
*Other medical experience (technicians, podiatrists, biochemist..etc, as indicated in Professions Ancillary to Medicine Lists (Department of Health)
*Complementary medicine experience
*Medical experience (medical nurse and medical auxiliary professions) describe duties and years of practice
All cheques payable to the Biomedic Foundation (the Charity) I would like to pay full fee of £1,160.00
I would like to pay each month quarterly instalments of £290.00
My course fee is financed by Health Authority or employer
*Name and telephone/E-mail of the financing body

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