...Post Code: Work Tel: Home Tel: Email: .. Contact number of next of kin: .... Job Title: .Grade: ... Department: ....Hospital: .. Please make cheques payable to:
West Hertfordshire Hospitals NHS Trust (ALS fund)
Cheques or details of payment arrangements (ie study leave) must accompany this application form. ONCE A PLACE HAS BEEN CONFIRMED NO REFUNDS WILL BE GIVEN. IF YOU CHANGE ADDRESS/CONTACT DETAILS YOU MUST INFORM US IMMEDIATELY.