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 / GenderOther 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 NameMobile 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 PakistaniIndian 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