E-Mail Form
Personal Information
 
First Name:
Last Name:
E-Mail Address:
Sex: Male: Female:
Nationality :
Passport No :
College Details  
Name of Institution:
Address of Institution
Telephone No:
Fax:
Email Address:
Contact Person:
Training Details  
Degree/Diploma of Study
Period of Study
Year of Study:
Subject matter covered :
State objectives of your elective term tour
How many hours/day do you plan to spend at the hospital?
Any special areas you would want to experience?
Accomodation Details  
Your Preference Hotel Hostels:(limited)
Other (Specify)
What other facilities in the country would you like to tour?
Have you made prior arrangements for (E)?
   

 

 

 


    

 


P.C.E.A Kikuyu Hospital, P.O Box 45 00 902 Kikuyu, Kenya Tel: 254-02-2044766 / 2044767 / 2044768 Fax: 2044765
E-mail:kikuyu@pceakikuyuhospital.org
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