Professional Documents
Culture Documents
online:
• Process complaints
You do not need to provide documents with this application form. They will be checked at a later stage.
You must complete all sections of this form marked with a *. If the form is incomplete it may be returned to
you.
Fee
Please enclose the correct fee of £230 with your application. If you hold refugee status please see our website (www.gmc-uk.org) or
contact us for the appropriate fee.
First name*
Other names
Postcode* Country*
Passport number
Refugee status
(If you hold Refugee status in the UK please tick one option below)
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 2 of 7
English language declaration*
(Please tick one option below.)
a) I have passed an English language test (Please choose from one of the options below)
I am a new graduate and obtained my primary medical qualification (PMQ) from a university where the
b)
language of instruction and examination is English.
I am not a new graduate and obtained my PMQ from a university where the language of instruction and
c) examination is English and have practised continuously for the two years immediately preceding this
application in a country where the language of professional practice is English.
I have passed an English language test for the purposes of obtaining registration with one of the medical
d) regulatory authorities indicated on your website and I have continuously practised in that country for the
two years immediately preceding this application.
You must provide evidence to prove your English language declaration. Please see our website (www.gmc-uk.org) for more information.
Your primary medical qualification (In most cases your primary medical qualification is your first medical degree.)
Full title of your primary Name and full address (including Date training Date training Date
medical qualification* country) of the university (and college started* finished* qualification
if appropriate) that awarded your awarded
qualification*
DD/MM/YYY DD/MM/YYY
DD/MM/YYYY
Y Y
Other medical schools you have attended Date training Date training
started finished
DD/MM/YYY DD/MM/YYY
Y Y
DD/MM/YYY DD/MM/YYY
Y Y
DD/MM/YYY DD/MM/YYY
Y Y
Has any part of your primary medical qualification been undertaken by remote or distance
PMQ2 learning? (eg a period of study undertaken solely by internet or through correspondence-based YES/NO
learning)
(If yes please provide details on a separate sheet.)
Is your primary medical qualification acceptable for the purpose of registration in the country that
PMQ3 awarded your qualification? (eg subject to internship, further training or examination) YES/NO
(If no please provide details on a separate sheet.)
1. Date D D M M Y Y Y Y Venue
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 3 of 7
2. Date D D M M Y Y Y Y Venue
3. Date D D M M Y Y Y Y Venue
The GMC is committed to treating everyone fairly and meeting our legal responsibilities under the Equality Act 2010 and
related legislation (such as the Human Rights Act 1998). One of the ways we do this is by asking people to provide
information about their ethnicity, disability, gender, sexual orientation, religion and beliefs.
Giving us this information is optional. If you choose to give it to us, we will keep it confidential and hold it securely in line
with data protection and other relevant legislation. We will use the information you give us to analyse and report on
statistical trends in medical education and practice in the UK. We will anonymise/pseudonymise any data we publish so
you can’t be identified.
The information may be used by different teams at the GMC. We may also share your personal data with other parties if
required by law, where ordered by a court, or where it is otherwise in the public interest (for example for research
purposes). Where possible, data will be anonymised or pseudonymised before we share it with any other party.
This information will not be shared with teams that make a decision about your application or your fitness to practise.
Ethnicity
• 'White British' includes the categories of White English, White Welsh, White Scottish and White Northern Irish.
Disability
The Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial
and long-term (i.e. has lasted or is expected to last at least 12 months) and adverse effect on the person’s ability to carry
out normal day-to-day activities.
The list of categories includes all the options from the census 2011 for England, Northern Ireland, Wales and Scotland.
Ethnic origin
White
Mixed
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 4 of 7
Indian Pakistani
Bangladeshi Chinese
Caribbean African
Arab
Christian - Methodist
Sexual orientation
Bisexual Other
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 5 of 7
Lesbian/Gay
Disability
Disabled but prefer not to give details Mental illness e.g. depression
Mobility - e.g. difficulty walking short distances or Other impairment - e.g. epilepsy, asthma, cancer or
climbing stairs facial disfigurement
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 6 of 7
Final Declaration*
I confirm that the information I have provided in this application is true and accurate.
I understand that any false declaration in any part of this application or false information or documentation provided in
support of this application may result in the GMC withholding or removing my registration, even if I have passed the test.
I confirm that I have read and understood the Guidance for PLAB test candidates on your website.
I understand I may be charged a cancellation fee if I decide to cancel or change my test place.
I understand that a decision about the acceptability of the qualification will not be made until the GMC have received an
application for registration. The criteria for acceptability change from time to time and that means that I could take the PLAB
test but find that my qualification is not acceptable for the purposes of registration. Full details of the current criteria can be
found on the GMC website.
I understand that by presenting to sit the PLAB Part 1 exam I declare myself fit to sit the exam.
I will be required to produce evidence of my identity when I attend for Part 1 or 2 of the PLAB test. This must be in the form
of my passport, or United Kingdom Immigration and Nationality Department Identification Document, or a home office travel
document, or a United Kingdom driving license. The evidence must bear my photograph.
My photograph will be taken when I attend for Part 2 of the PLAB test for future verification of my identity.
My personal data, including my photograph, and any of the information I provide to the GMC may be:
• disclosed to Government agencies, employers, overseas regulators (including outside the EEA) and other third
parties where required by our procedures, by law or as may be reasonably necessary
• used by the GMC, their representatives, and any other agent that the GMC ask to carry out checks on its behalf, to
make any necessary checks to verify the information I have given, including checks on my English language
proficiency, employment, qualifications and the accuracy of any information provided
• used by the GMC and its partners for research purposes
I have read the guidance on acceptable overseas qualifications and understand and accept the statements above.
Signature*
Date*
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 7 of 7