Royalcollege of Surgeons in Ireland

RoyalCollege of Surgeons in Ireland

MedicalUniversity of Bahrain

MSc in Health Care Ethics and Law

Application Form 2011/2012

______

Please complete clearly

This form will be photocopied

PERSONAL DETAILS

Dr/Mr/Mrs/Miss/Ms/Other:
Surname/Family name:
Given name(s)/ First name(s):
Date of Birth:
Nationality:
Occupation:
Address:
Telephone (home):
Telephone (work):
Mobile:
E-mail:
Reasons for undertaking study
Please specify the name and telephone number of a person to contact in the event of an emergency.
Name:
Address:
Telephone number:

EDUCATION AND PROFESSIONAL EXPERIENCE

University or College attended and qualifications obtained or taken.

(Continue on a separate sheet if necessary)

University/College attended / From
(month/year) / To
(month/year) / Qualifications/Grades obtained if course completed (in case of a degree or diploma give class and division)

Profession and vocation qualifications and training

(Continue on a separate sheet if necessary)

Name of professional institution / From
(month/year) / To
(month/year) / Qualifications awarded and subjects studied

Registerable qualifications

(Continue on a separate sheet if necessary)

Name of Institution / From
(month/year) / To
(month/year) / Qualifications / Date registered

English Language

Is English your first language / Yes / No

If not, please supply evidence of capacity in the English Language.

Professional experience

Name and address of employer / Job title/brief description of role / Starting date
(month/year)

Previous professional experience

Name and address of employer / Job title/brief description of role / Starting date
(month/year)

Referee details

Please give the names and titles of two persons, one of whom should be able to comment on your ability to study at university.

Name / Address / Telephone / E-mail

Declaration

I confirm that to the best of my knowledge, the information given in this form is true, complete and accurate and no information requested or other material information has been omitted. I give my consent to the processing of my data by the Royal College of Surgeons in Ireland-Medical University of Bahrain. I understand that any offer of a place on the above programme is subject to my acceptance of the RCSI-MUB’s terms and conditions. I accept that if I do not fully comply with these requirements, the RCSI-MUB reserves the right to cancel my application and I shall have no claim against the RCSI-MUB in relation to this application.

Applicant’s signature ……………………………………………………………

Date ……………………………………..

Please ensure that you have enclosed the following:

Tick box

Two passport sized photographs.

Photocopies of relevant University degrees or diplomas and professional qualifications.

Acceptable evidence, if necessary, of your command of the English language.

Completed application form should be returned to:
Ms. Rachel Towers, Admissions Office, RCSI-MUB, PO Box 15503, Adliya, Kingdom of Bahrain.
Building 2441, Road 2835, Block 228, Busaiteen, Kingdom of Bahrain