CLINICAL ADVISORS & EXPERTS APPLICATION FORM

If not submitting an electronic application, please write clearly in blue or black ink.

SECTION 1 - PERSONAL DETAILS
GDC REGISTRATION NUMBER: / REGISTRANT TYPE:
TITLE: / Mr. Mrs. Miss Ms. Dr. Prof. other ______
FORENAME (S): / SURNAME:
ADDRESS:
POSTCODE: / EMAIL ADDRESS:
HOME TELEPHONE: / MOBILE TELEPHONE:
Please indicate where you heard about this role?
Twitter * GDC website * Colleague * Facebook  Direct email 
Other, please specify……………………………………………………….
Please attach a CV of no more than 4 pages with details of your professional qualifications, a full career history, (including paid and unpaid activities), significant positions and responsibilities held, relevant achievements and anything else you consider relevant to the role

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SECTION 2 – PERSONAL STATEMENT
Please state in no more than 500 words why you believe you are suitable for the role. Please continue on a separate sheet, if necessary.
SECTION 3 – RELEVANT EXPERIENCE
Please use the space below to outline any previous experience you have of either providing clinical advice or acting as an expert witness
SECTION 4 – PROFESSIONAL ORGANISATIONS & INTERESTS
Membership of professional organisations
Please provide details of any memberships you hold with professional organisations
Date joined / Organisation / Membership status
Areas of interest and/or expertise
Please indicate your particular areas of interest and/or expertise:
General Dental Practitioner / Restorative Dentistry
Special Care Dentistry / Dental Public Health
Oral Surgery / Oral Medicine
Orthodontics / Oral Microbiology
Paediatric Dentistry / Oral and Maxillofacial Pathology
Endodontics / Dental and Maxillofacial Radiology
Periodontics / Implants
Prosthodontics / Other (Please state below)
SECTION 5- REFERENCES
Please give the name, address and telephone number of two referees. One of which should be a professional reference.
NAME OF REFEREE:
ADDRESS:
POST CODE:
TELEPHONE NUMBER: / EMAIL ADDRESS:
RELATIONSHIP TO APPLICANT? (E.g. business, personal, clinical colleague etc)
NAME OF REFEREE:
ADDRESS:
POST CODE:
TELEPHONE NUMBER: / EMAIL ADDRESS:
RELATIONSHIP TO APPLICANT? (E.g. business, personal, clinical colleague etc)
SECTION 6 – DECLARATION OF INTERESTS
Do you have any business or personal interests that might be relevant to the work of the General Dental Council and which could lead to a real or perceived conflict of interest if you were asked to act as a clinical advisor or expert? (This includes any affiliation to programme(s) that leads to registration with the GDC)
SECTION 7 – PROFESSIONAL ADVISOR
The GDC holds Registration Appeals hearings for dentists and dental care professionals who have been refused registration by the GDC. For those appeals where registration is refused on the basis of inadequacies in dental education and training, the GDC appoints a Professional Advisor to sit with the panellists considering the case. The professional advisor’s role at the hearing is to ask the registrant questions about the information they have submitted in support of their registration application, and also to advise the panel on issues relating to education and qualification.
Would you be interested in receiving more information about the role?
YES  NO 
SECTION 8 – OTHER REGULATORS
Have you ever been, or are you currently, registered with another healthcare regulator?
YES  NO 
If yes, have you ever been subject to a fitness to practise investigation by that healthcare regulator?
YES  NO  n/a 
If yes, please provide details below.
SECTION 9 - DECLARATION
I declare that the information contained in this application is complete and correct. I understand that my application may be rejected, or if I have been selected for inclusion on the list that I may be removed, for withholding relevant details or giving false information.
I agree that the General Dental Council may use the information provided in this application for monitoring purposes: YES * NO *
[We will treat all your data in accordance with the Data Protection Act 1998]
*SIGNATURE: / DATE: / / /
DD MM YYYY
NAME:

*PLEASE SIGN IF COMPLETING BY HAND. IF COMPLETING AND EMAILING, PLEASE TYPE YOUR NAME AND YOUR EMAIL.

Thank you for taking the time to complete this application.

Please completed application form, a copy of your CV and equality and diversity monitoring form to Tina Ravji at .

Alternatively, please send your application form and a copy of your CV to

Tina Ravji

Corporate Operations Manager

FtP Casework
General Dental Council
37 Wimpole Street
London
W1G 8DQ

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CONFIDENTIAL – TO BE DETACHED AND USED FOR MONITORING PURPOSES ONLY

Equality Monitoring Form

The GDC is committed to promoting and developing equality and diversity in all our work. We want to be sure that our policies and ways of working are fair and do not discriminate against individuals or groups. To help us to monitor the effectiveness of our policies and practices we ask you to complete the monitoring form. This information will be treated in the strictest confidence under the Data Protection Act 1998 and will be used to produce statistics to enable the GDC to look at the diversity profile of our staff, registrants and others with whom we work. Through this we can check a variety of processes to ensure equality and address issues as they arise

AGE

16-21 22-30 31-40 41-50 51-60 61-65 over 65 Prefer not to say

DISABILITY

Do you consider yourself disabled?

Yes No Prefer not to say

(The Equality Act 2010 defines disability as a physical or mental impairment which has substantial long-term effect on a person’s ability to carry out normal day-to-day activities.)
RACE


Asian or Asian British Mixed Ethnic Background

Bangladeshi White and Asian

Indian White and Black African

Pakistani White and Black Caribbean

Any other Asian background Any other mixed ethnic background

(please specify)______(please specify)______

Black or Black British White

  African British

  Caribbean Irish

  Any other Black background Any other white background

(please specify)______(please specify)______

Chinese or any other ethnic group

  Chinese

  Any other ethnic background Prefer not to say

(please specify)______


SEX

Female Male  Prefer not to say

GENDER IDENTITY

Is your gender identity the same as the gender you were assigned at birth?

 Yes  No  Prefer not to say

RELIGION/BELIEF

  Buddhist  Christian  Hindu  None

  Jewish  Muslim  Sikh  Prefer not to say

  Other religion / faith (please specify) ______

SEXUAL ORIENTATION

  Bisexual Gay man Gay woman

  Heterosexual Prefer not to say

MARITAL STATUS

  Civil partnership Divorced Married Separated

  Single Widowed Prefer not to say


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