Patient Safety & Clinical Risk Management in Informatics Programme Application Form

Name

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Last

Job Title

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 your lnformatics aspirations for the next 5 years

In no more than 100 words please tell us why you would like to participate in the Patient Safety & Clinical Risk Management in Informatics Programme

Purchase Order Number

Invoice F.A.O

Invoicing Organisation Name

Invoicing Organisation Address

Please attach the Purchase Order here

Maximum file size: 52.43MB

By selecting this box you are agreeing to attend the full programme and paying the cost of the programme in advance of the day

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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Last

Line Manager Email

If you are human, leave this field blank.