Registered Medical Practitionersapplication Form (Ref: GOC17/05)

Registered Medical PractitionersApplication Form (ref: GOC17/05)

Companies, Education, Standardsand Investigation Committees

This application form is available in alternative formats (for example, braille, audio or large print). Please submit your request to the Governance team ().

There are 10 sections to complete in this application form, please ensure you have completed them all. Deadline:12:00pm on Wednesday 8 November 2017

SECTION ONE: PERSONAL DETAILS
Title:
Surname:
Forename(s):
Full home address (with postcode) :
Email address:
Telephone number (home):
Telephone number (mobile):
Where did you learn about the vacancy?
GMC no:
Which Committee(s) are you applying to?
Please note, successfully appointed candidates can usually only sit on one committee. / Education Companies
Standards Investigation
SECTION TWO: RELEVANT EXPERIENCE
Please attach a brief, up-to-date Curriculum Vitae (CV) (no more than 3 sides A4) as a separate document to your application. Your CV should outline: your experience, including relevant employment history; any relevant voluntary work, public service or other experience; and any relevant professional, academic or vocational qualifications. NB: CVs alone will not be accepted. Your CV will be used to assist the assessment of your expertise.
Current (or most recent) relevant position held and date of appointment:
SECTION THREE: ESSENTIAL CRITERIA
Please indicate how you meet the essential criteria detailed in the person specification. It is important that you use examples which are based upon real situations, clarify the task you had to achieve, outline the action you took and identify the result of your action(s). If necessary, you may use the same evidence or example against more than one criterion.
Please note that all applicants are expected to provide examples for each criteria in this section (i.e. 3A, 3B, 3C, 3D, 3E, 3F and 3G).
3A. Please give evidence of your ability to provide objective advice. Please use no more than 300 words.
3B. Please give evidence of yourability to listen, communicate and influence effectively.Please use no more than 300 words.
3C. Please give evidence of yourability to build effective relationships and work effectively as part of a team. Please use no more than 300 words.
3D. Please give evidence of demonstrable commitment to equality, diversity and inclusion – dealing with people and issues honestly, fairly and with respect.Please use no more than 300 words.
3E. Please give evidence of your analytical capacity, intellectual flexibility and sound judgment. Please use no more than 300 words.
3F. Please give evidence of yourunderstanding of professional regulation and its impact. Please use no more than 300 words.
3G. Please give evidence of yourunderstanding of primary and/or secondary care services for patients with optical needs. Please use no more than 300 words.
SECTION FIVE: REFERENCES
Please give details of two professional referees who you consider are best placed to support your application.

“Professional referees” refer to individuals who have observed you acting in a productive capacity where you have displayed the skills/knowledge relevant to the role in question. Examples include former employers, colleagues, supervisors or professors.
Wewill not accept personal references, for example from family members or friends.
Wewill not accept references from GOC employees.
Wecan accept references from Council, Committee or Hearings Panel members who are not involved in the selection process provided they know you outside of their role at the GOC.

References will be asked for the successful candidates as soon as the candidate is offered appointment. An appointment will not be confirmed until we have received two satisfactory references.
REFEREE 1
Name:
Relationship to you:
Organisation:
Telephone number:
Email address:
REFEREE 2
Name:
Relationship to you:
Organisation:
Telephone number:
Email address:
SECTION SIX: DISQUALIFICATION CRITERIA
In accordance with the requirements stated in the information pack, you are required to confirm that none of the disqualification criteria set out in Annex A of the information pack apply to you.
Can you confirm none of the disqualification criteria set out in Annex A of the information packapplies to you? / Yes No
SECTION SEVEN: DECLARATION OF INTERESTS
Please read the section on management of interests in the candidate pack carefully (section 5 of the candidate pack).
Do you have any business or personal interests that might be relevant to the work of the GOC and which could lead to a real or perceived conflict of interests were you to be appointed? / Yes No
If Yes please give details:
Do you have any close personal relationships with other GOC members or employees that may be perceived as a conflict of interest? / Yes No
If Yes please give details:
SECTION EIGHT: ENSURING PUBLIC CONFIDENCE
Should you be successful in your application, is there anything about your professional or personal history which, if brought into the public domain, may cause embarrassment or disrepute to the GOC. / Yes No
If Yes please give details:
SECTION NINE: INTERVIEW AVAILABILITY
Are you available to attend an interview on the published interview date (as specified in section three of the candidate pack)?
Please note that on the occasion you cannot attend the interview date published, the Selection Panel may consider a new date, but at their discretion and in light of those interviewed first time. / Yes No
SECTION TEN: DECLARATION
I have completed the GOC EDI monitoring form.
Please note that you are required to submit an EDI monitoring form which will be separated from your application prior to shortlisting. We are committed to equality and diversity and completion of this form is a mandatory requirement of your application. / Yes No
I declare that the foregoing information is correct to the best of my knowledge and belief and I have included all material facts which may have a bearing on my application. / I agree that the General Optical Council may use the information provided in this application for monitoring purposes.
We will treat all your data in accordance with the Data Protection Act 1998
Signed:
If emailing, type name. / Yes No
Date:

Thank you for taking the time to complete this application form.

Please return the application form, a copy of your CV (maximum 3 A4 pages), and any monitoring forms by email to: .

To ensure our IT systems can open your application safely, please send in Microsoft Word or PDF format.

Once you have submitted your application, we will acknowledge safe receipt within two working days.

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