Application Form number:

(For Medical personnel use only)

APPLICATION FOR EMPLOYMENT MEDICAL/DENTAL STAFF

ALL INFORMATION WILL BE TREATED IN CONFIDENCE

PLEASE READ THE INSTRUCTIONS ON PAGE 6 BEFORE COMPLETING THIS

APPLICATION FORM

PLEASE DO NOT SUBMIT A CURRICULUM VITAE

Please complete all appropriate sections of this form.

Please use black ink or type.

Post applied for:
Speciality/Department:
Location(s):
Job Ref. No:

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EMPLOYMENT DETAILS

PRESENT POST
Grade: / Specialty:
(Indicate if Honorary Status is applicable)
Date Appointed: / Base Hospital:
Basic Salary: / Incremental Date:
Expected Date of Termination of Appointment:
Employment Authority or University:

Please give details of previous employment history since Medical School, ensuring that all service is listed. This section should be completed in date order with your current or most recent job first

Name and address of Employer or Organisation / Grade of Post/Title of Post
(Indicate if Honorary Status applicable and grade) / From Date
(Day, Month and Year) / To Date
(Day, Month and Year) / Duration of Post in Months

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EDUCATION, TRAINING AND QUALIFICATIONS

Please give details of educational and professional qualifications. You will be required to produce evidence of relevant qualifications at a later stage.

EDUCATIONAL AND PROFESSIONAL QUALIFICATIONS

Education and Qualifications / Grade Obtained / Year Obtained / Examining Body

HONOURS AND AWARDS

Grade Obtained / Year Obtained

TRAINING QUALIFICATIONS

Course(s) currently being undertaken leading to a postgraduate qualification / Grade/Level of Course / Expected Date of Qualification

PLEASE GIVE DETAILS OF ANY OTHER RELEVANT TRAINING UNDERTAKEN OR COURSES ATTENDED:

Title of Course or Subject / Date Attended/Course Completed

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PROFESSIONAL REGISTRATION

GMC/GDC Registration Number: / Full / Temporary:
Licence to practice with GMC? Yes / No / YesNo
Date of Expiry of Current Registration:
Name of Medical Defence Organisation if applicable:
Registration Number: / Renewal Date:

TO BE COMPLETED FOR SPECIALIST REGISTRAR/SPECIALTY REGISTRAR POSTS ONLY

Do you hold a current National Training Number (NTN), Yes / No? / YesNo
If yes, please state your NTN number:
Specialty:
Location:
Have you ever previously held an NTN, Yes / No? / YesNo
If yes, please give details of dates held, which specialty etc:

TO BE COMPLETED FOR CONSULTANT POSTS ONLY

Since 1 January 1997, it has been a legal requirement for all doctors to be on the GMC’s Specialist Register or have an expected CCT date no more than 6 months from the date of interview before they can be appointed to a Consultant post.
Please complete the following:
Are you on the Specialist Register, Yes / No? / YesNo
If yes, date of entry:
If no, what is your expected CCT date:

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Supporting Information

Having reviewed the job description and person specification, you should use this section of the form to make a statement about your career intention and to provide additional information in support of your application.

Please indicate details of previous duties and responsibilities, clinical experience, publications, interests etc.

Please continue on a separate sheet(s) if necessary
(please number additional sheets, alphabetically i.e. 5a, 5b etc).
CLINICAL REFERENCES (Please read carefully)
A minimum of 2 referees are required and must include current (most recent) and immediate previous appointment unless your application is for a consultant appointment. If this is the case please provide us with a third referee.
In any event, the referees that you supply must cover at least the preceding three years of your employment.
Additional space is provided however; if you need to supply more details please attach a separate sheet to your application.
Your referees must be able to comment on your suitability for the post including any secondments or overseas fellowships of a duration of six months or more.
1. Name: / 2. Name:
Designation: / Designation:
Address: / Address:
Post Code: / Post Code:
Telephone: / Telephone:
Email: / Email:
Fax: / Fax:
FOR CONSULTANT APPOINTMENTS ONLY / ADDITIONAL REFEREE DETAILS
3. Name: / 4. Name:
Designation: / Designation:
Address: / Address:
Post Code: / Post Code:
Telephone: / Telephone:
Email: / Email:
Fax: / Fax:

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EMPLOYMENT REFERENCES
You are required to provide references which cover the last three years of your work history. These references will be taken up directly with the HR Department. Please give details of all employers including those that relate to the employment given in your Application form for the last three years.
Any delay in providing this information may defer your commencement.
1. Name: / 2. Name:
Position: / Designation:
Address: / Address:
Post Code: / Post Code:
Telephone: / Telephone:
Email: / Email:
3. Name: / 4. Name:
Position: / Designation:
Address: / Address:
Post Code: / Post Code:
Telephone: / Telephone:
Email: / Email:

INSTRUCTIONS/GUIDANCE FOR COMPLETING THIS APPLICATION FORM

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