1

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:




2
EMPLOYMENT DETAILS

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







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:


3
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
4



















5
PROFESSIONAL REGISTRATION

GMC/GDC Registration
Number: Full / Temporary:


Licence to practice with GMC?
Yes / No


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?


If yes, please state your NTN number:
Specialty:
Location:
Have you ever previously held an NTN, Yes / No?


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
GMCs 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?


If yes, date of entry:


If no, what is your expected CCT date:


6
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).
7


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:
Designati
on:

Designati
on:

Address: Address:




Post
Code:

Post
Code:

Telephon
e:

Telephon
e:

Email: Email:
Fax: Fax:



FOR CONSULTANT APPOINTMENTS ONLY

ADDITIONAL REFEREE DETAILS


3. Name: 4. Name:
Designati
on:

Designati
on:

Address: Address:




Post
Code:

Post
Code:

Telephon
e:

Telephon
e:

Email: Email:
Fax: Fax:
8

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















Please do not submit a curriculum vitae.

Read all the material provided in the information pack that has been sent to you. This will give you the
opportunity to assess whether the post is suitable for you.

Consider all the points you wish to make in support of your application

Make sure that your application is geared around the job you are applying for.

Provide detail about your present and previous posts. This will show the skills you are currently using and
may uncover areas you may not think are important.

Use the section on page 5 of this form to provide a statement about your career intention and other relevant
information. If including additional pages to this section please number additional sheets alphabetically i.e. 5a,
5b etc. Please ensure you do not include personal details which are incorporated on the equal
opportunities monitoring form.