Common Stations LTD

I Full Name
Booking Reference Number
Date of Birth
Country of origin
GMC Number
PLAB 2 Exam Date

WhatsApp No.:
Contact Numbers
UK No.:

Registered □ Date: ……… to ………

5 days face to face Workshop Attended □

Not Attended □

Gender
Height (cm)

Weight (Kg or Stones)

Married Single Other
Marital Status

(For female doctors only) Are you YES NO

pregnant? If so, how many weeks? ______
YES NO
Do you have any visual problem?
If yes, please specify _________________
YES NO
Do you have any medical conditions? If yes, please specify _________________
Do you have any known mental YES NO
health issues? If yes, please specify _________________
YES NO
Do you have any known disabilities? If yes, please specify _________________
hereby certify that all the information above has been completed to the best of my knowledge and all
the information provided is accurate.

Signed ______________________________________

Date: ______________________________________

This document will be kept strictly confidential and is for office use only.