The closing date for this application is 15 November 2017

Title:
(Mr/Mr/Miss/Ms/Dr) / Surname: / Forename(s):
Gender (M/F):
/ GDC Number:
/ FGDP(UK) Membership Number:
CONTACT INFORMATION
Daytime tel:
Evening/home tel:
Mobile tel:
E-mail address:
House name/ number:
Street name:
Town:
County:
Postcode:
Country:
Date of qualification day/month/year:
COURSE FEES
£1,400 FGDP(UK) non-members’ rate / £1,000 FGDP(UK) members’ rate
PAYMENT METHOD
I enclose a cheque payable to Faculty of General Dental Practice (UK)
I wish to pay by credit/debit card
Mastercard / Visa / Switch / Delta
Card Number:
Expiry Date: / Issue No: / Security Code:
Card Holder Name:
Card Holder Signature:
DISABILITY DISCLOSURE
Whenever possible we wish to ensure that appropriate adjustments are made for applicants who disclose a disability. If you identify as disabled under the Disability Discrimination Act 1995 then please inform us of both your condition and of any adjustments which you may require.
DIETARY REQUIREMENTS
Please detail any specific dietary requirements
MISCELLANEOUS
Where did you hear about the course?
Newspaper/Publication / Please specify
Website/Internet / Please specify
Word of Mouth
STUDENT DECLARATION
Cancellations incur an administration charge of 10% (or £50, whichever is greater) of the total course fee. However, within four weeks prior to the start date of the course, the total course fee will be charged, unless in exceptional circumstances at the discretion of the faculty.
FGDP(UK) will not authorise deferrals of attendance of days 3 & 4 to a future intake nor permit course fees to be transferred to future cohorts.
Whilst we make every effort to run courses as advertised, we reserve the right to change the timetable and/or teaching staff without prior notice, and to cancel any courses without liability (in which case there will be a full refund of course fees to participant). Note that any consequential losses (eg. travel or accommodation costs) incurred in such cases remain the responsibility of the booker, and consideration should be made to taking out appropriate travel insurance for any non-refundable costs.
By signing this document I agree to these terms.
Signature: / Date:
Please return your completed application to:
Course Organiser, FGDP(UK), The Royal College of Surgeons of England, 35-43 Lincoln’s Inn Fields, London WC2A 3PE or e-mail to
PLEASE NOTE THAT THIS COURSE IS TAUGHT EXCLUSIVELY IN ENGLISH
DATA PROTECTION ACT
This information will be held in accordance with the Data Protection Act used for the purposes of course administration relating to the Periodontics Short Course.
We would like to keep you informed of other events and activities that may be of interest to you, please tick this box if you do not wish to receive these mailings.

In line with UK legislation and good practice guidelines, we request that everyone completes this section. You are not obliged to provide any of the information in this section, but if you do so, it will enable us to monitor our business processes and ensure that we provide equality of opportunity to all.

Name: / Ethnicity
Choose one selection from the list below to indicate your cultural background:
a)White:
British
Irish
Any other White background
b) Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
c) Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
d) Black or Black British
Caribbean
African
Any other Black background
e) Chinese or other ethnic group
Chinese
Any other background
Indicate a more specific category here:
Gender:
Nationality:
1st Language:
Do you have a disability under the terms of the Disability Discrimination Act 1995 (a person with a physical or mental impairment that affects you ability to carry out normal day to day activities which are substantial, adverse and long term)?
Yes
No
What is your sexual orientation?
Bisexual
Heterosexual
Lesbian or Gay
What is your religion or belief?
Buddhist
Christian
Hindu
Jewish
Muslim
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Other religion/belief
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This information will be recorded with your other data in accordance with the Data Protection Act 1998, but used only for monitoring our business practices.