ICL Application Form - NHS Clinical Leaders Network

ICL Application Form

Name

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Last

Qualifications

Job Title

Professional Group

If Other, please specify:

Region

Organisation

Contact Tel. No.

Contact Email

How did you hear about us?

If social media or other, please specify:

Please share any previous leadership development courses you have attended

In no more than 100 words please tell us why you would like to participate in the CLN Introduction to Leadership Programme

0 of 100 max words

(Enter discount code)

Purchase Order Number

Invoice F.A.O

Invoicing Organisation Name

Invoicing Organisation Address

Please attach the Purchase Order here

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By selecting this box you are agreeing to pay the cost of the programme in advance of day 1

I agree

By selecting this box and completing the contact details you agree that you have received written approval from your line manager

I agree

Line Manager Name

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Line Manager Email

If you are human, leave this field blank.