Application for Appointment of

Examiners (Dental Radiologist/Medical Radiologist) to the DDMFR Examination Board

If Handwritten, Please Complete in Block Capitals

Applicant's Surname / Date of Birth / Gender
Other Names (in full)
Hospital Address
Date of FRCR Admission / Date of Consultant Appointment / Vacancy applied for (pls delete)
Dental Radiology/Medical Radiology
Main Contact Number / Email address

Applicant's Statement

You should provide a statement describing why you believe you would make an appropriate examiner. This statement should be restricted to the space provided here:
Applicant's Signature
I confirm I am aware of theFRCR Policy on Examiners’ Conflicts of Interest / Date

Supporting Statement

A statement from both supporters should be provided describing why each believes the applicant would make an appropriate member of the DDMFR Examination Board. This statement should be restricted to the space provided here:

Each Supporter Should Complete the Appropriate Section Below
First Supporter’s Full Name / Hospital Name
Mobile Number / Email address
Date of FRCR Admission (if appropriate) / Date of Consultant Appointment
Signature / Date
Second Supporter’s Full Name / Hospital Name
Date of FRCR Admission (if appropriate) / Date of Consultant Appointment
Signature / Date

This form, once completed, should be returned to

Sharon Dinsdale, The Royal College of Radiologists, 63 Lincoln’s Inn Fields, London WC2A 3JW

OR by email to

to arrive no later than 4 pm on Friday 27 October 2017.

DIVERSITY MONITORING FORM

Collecting this data will help The Royal College of Radiologists to meet the recommendations of the Equality and Human Rights Commission (EHRC). The information given here will be treated as confidential. It will only be accessed by authorised individuals at the College and will not be disclosed to any other bodies or individuals. Statistics derived from this data will be used for monitoring purposes, may be published and may be passed to other bodies.

Post applied for:

Gender Information:Female Male

What is your cultural background?These categories are not about nationality, place of birth or citizenship. They relate to broad ethnic group categories as recommended by the EHRC. Choose ONE category from A to E that accurately describes you, then circle as appropriate or tick the appropriate line to indicate your background. The categories were those used in the 2011 Census.

A. Asian, Asian British
Bangladeshi Pakistani
Indian Chinese
Any other Asian background – please describe
B. Black, African, Caribbean, Black British
African Caribbean
Any other Black/African/Caribbean background - please describe
C. Mixed, Multiple ethnic groups
White and Black African White and Black Caribbean
White and Asian Any other Mixed background – please describe
D. White
English Welsh British
Scottish Northern Irish
Irish Any other White background – please describe
E. Other ethnic group
Arab Any other ethnic group – please describe

Do you consider you have a disability? (Please tick)Yes No

Nature of your disability

Please return this form to the Governance and Council Officer (), The Royal College of Radiologists, 63 Lincoln’s Inn Fields, London WC2A 3JW