2
2012
PRIN
NT Ap
pplicationn
O
Only compleete the form if you are cerrtain you want to underta
ake a PRINTT placement

Name

....................................................................................

U Numbeer

....................................................................................

I would likee to do a PR
RINT term from
f
Tuesdday 30 Octob
ber 2012 for a minimum
m of 3 week
ks.
(Students w
wishing to sttay longer th
han 3 weeks
ks may be ab
ble to do so, after nego tiation with
h the
departmentt)

My preferences are:

Hospital

TCH
H

Calvary
y

Goulburnn

(In ordeer of
prefereence:
1 to 33)

Departm
ment

Medicinee

Surggery

O&G

(in ordeer of
Preferennce:
1 to 44)

Please returrn form to Ms
M Antoni Grech
G
by Frriday 13 Jully 2012

1 | ANU MEDICAL SCHOOL

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