European Board of Medical Genetics

Form A. Notification of Intention to Register Form

Applicants applying by the usual route

1.  Your personal details

Last or family name
First name
Previous or maiden name (if applicable )
Gender / Male / female
Date of birth
Email
2nd email
If we need to post documents to you, should we post then to your home or work address? / Post to home address
Post to work address
Are you applying for registration as a genetic counsellor or genetic nurse? / Genetic counsellor
Genetic nurse

2.  Your home address

Home address
Home postcode
Country of residence
Home telephone (optional) (with international code / +

3.  Your work address

Work address
Work postcode
Country in which working
Work telephone (with international code) / +

4.  Your qualifications

Professional qualifications / Genetic counselling master degree Yes / no
Genetic nursing master degree Yes / no
Academic qualifications, institution and year obtained / Diploma in:
Bachelor or undergraduate degree in:
Other masters in:
PhD title:
Other academic qualification:

5.  Your employment

History of employment as a genetic counsellor or genetic nurse (including public, private, charity) / Gives dates and institutions, most recent first
Have you worked for at least 2 years full time (or equivalent part time) in a genetic counselling post / Yes/no
Please give dates and institution(s)
Please tell us about all your relevant current posts
Current job title
Full or part time / Full time
Part time (% worked or hours per week)
Current employer
Name of current manager
Name of senior colleague providing reference
For our information, can you tell us why you wish to register?

Applicant’s signature ……………………………………… Date ……………………………..

Manager’s signature ………………………………………. Date ………………………………
Senior colleague’s signature …………………………… Date …..………………………….

Document Checklist

I attach the following documents with this completed form:

Copies of relevant academic/professional certificates (mandatory)

A fee of €200 should be made payable to the European Board of Medical Genetics.

Updated GCRB November 2011 - 2 -