Application Form

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Name*
First Last
Email*

Phone*
Job Title*

Organisation*

Work Address*

County*
Are you currently working in a specialist ambulatory care hub for chronic disease?*

Yes

No
Please provide details of the specialist ambulatory care hub you work in.*

What do you hope to gain from attending this course?*
Where did you hear about this course?*

Please select correct category for your CME/CPD/CEU attendance certificate:*

ICGP

NMBI

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The NIPC may contact you with relevant information about future courses/conferences. Please check the box if you would like to hear from us. We respect your personal data & take great care to ensure security & confidentiality are maintained.*

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