Efficiency, Quality and Sustainability in Healthcare Through Innovation Procurement

Leadership Programme for

Efficiency, Quality and Sustainability in Healthcare through Innovation Procurement

1-3 September, 2015

Madingley Hall, Cambridge, UK

To apply to join this programme, please provide us with the initial information requested below. Please complete all sections and email the completed form to . A member of our team will then be in touch.

Title:
First Name:
Last Name:
Job Position:
Organisation:
Address:
Country:
Email:
PA Email:
Telephone Number:
Gender: / Male / Female
(please delete as appropriate)
Please indicate your competency in the English language: / Listening: 1 2 3 4 5 6 7 8 9
Writing: 1 2 3 4 5 6 7 8 9
Speaking: 1 2 3 4 5 6 7 8 9
Please indicate your level on the scale above, where:
4 = Basic user
6 = Independent user
9 = Proficient user
Please enter a brief professional biography here:
Please outline your main reasons for applying:
How did you hear about the programme?
Do you want to apply for a grant to support for travel and accommodation costs? / Yes / No
(please delete as appropriate)
Please indicate the reason:

Declaration and Data Protection

DATA PROTECTION ACT (1998): I agree to Optimat Ltd (EcoQUIP Coordinator) and the University of Cambridge Institute for Sustainability Leadership (CISL) processing personal data contained in my application form whether provided by myself or by other individuals or institutions, in support of my application, as part of the administration and registration process. I accept that, should I be made an offer to attend the Leadership Programme, this information will be retained during and following the event for administration and for the provision of statistical returns.

I certify that the information given in this application is complete and accurate, and I understand that if I have given false or misleading information the University of Cambridge Institute for Sustainability Leadership will not admit me on to the programme and may take legal action against me. I understand that if my application is unsuccessful, the papers relating to it cannot be returned.

I agree to the above terms: YES (please circle to confirm)

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