Non-Consultant Hospital Doctor Application Form

NCHD Application Form
Candidate ID: 024279809
Non-Consultant Hospital Doctor Application Form

Section A - Personal Details
Candidate ID: First Name: Family Name: Address 1: Address 2: Address 3: Country: DayTime Number: Mobile Number: Date Of Birth: Email: PPS Number: Irish Citizen: EU Citizen: Citizenship Other:
024279809 Aqeel Chaudhry 136 kshmir block, allama iqbal town, lahore
PAKISTAN +923334038756 +923219432274 06/04/1985 draqeelchaudhry@hotmail.com
false false
Section A - SHO and Registrar specialty and sub-specialty roles
Role: Area: Preferred Specialty: Preferred Sub-Specialty: Second Specialty: Second Sub-Specialty:
Senior House Officer Surgery General Surgery
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Section A - Hospital Group / Mental Health Service Group Preferences
Hospital Group:
Dublin North East
Section B - Visa and Work Permit Status
Do you require a work permit to work in Ireland? Number on permit / visa Start date: End date: Do you hold a Garda National Immigration Bureau Card? The stamp number on my card is:
Yes
No
Section C - Irish Medical Council Registration
Are you registered with the Irish Medical Council (IMC)? If yes, please state the name in which you are registered IMC Registration Number Type of registration IMC acceptance letter reference number If not registered, have you applied for registration? The IMC Reference for your application is
No
No
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Section C - Training/Prior Experience
Are you enrolled in a Registrar Training Programme in Ireland at this current time? If yes, please select the postgraduate training body responsible for the Registrar training Programme Will you be applying to enter Higher Specialist Training in Ireland in 2012? If yes, please select the postgraduate training body you will be applying to Have you worked as a Senior House Officer or Registrar in Ireland before? If yes, please select the year you started work in Ireland. Do not include your intern year
No
No
No
page 3
Section D - Undergraduate Education
University/Medical School Name Address line 1 Address line 2 Address line 3 Address line 4 Country Date of entry to Medical School Date of graduation Primary medical qualification Overall grade achieved Exam Results Subject Medicine, surgery, paeds, Gynae & Obstetrics, Higher Qualification/Degree/Diploma Qualification Name : Awarding Body : Date of Qualification : Postgraduate Exams Postgraduate Exam Name : Grade Achieved : Date : Skill Courses Name of Course : Location of Course : Date :
Nishtar Medical college, Multan/ UHS Lahore, Pakistan nishtar road multan
Pakistan/Punjab PAKISTAN 14/01/2004 13/02/2009 MBBS A
Grade A
ACLS and Trauma Course AIMC, Jinnah hospital Lahore 26/06/2009
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Undergraduate Academic Distinctions Please give details of any prizes, medals or scholarships received
Postgraduate Academic Distinctions Please give details of any prizes, medals or scholarships received
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Section E - Employment History Clinical Site Shaukat Khanum memorial Cancer Hospital & Research Center Wazir Hospital, lahore Wazir Hospital, Lahore Mayo Hospital, lahore Mayo Hospital, lahore Mayo Hospital, lahore Grade RMO(Reside nt medical Officer) Specialty Surgical Oncology Date From 10/01/2012 Date To 04/05/2012 Months in post 3
RMO(Reside nt medical Officer) RMO
Surgery
01/01/2011
31/12/2011
12
Internal Medicine Thoracic surgery General surgery Internal medicine
17/05/2010
31/12/2010
Internee
16/03/2010
15/05/2010
Internee
16/11/2009
15/03/2010
Internee
16/05/2009
15/11/2009
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Section F - Publications, Audit & Presentation
page 7
Section G - Aims & Career Objectives Outline your career objectives, why you wish to gain employment with the HSE as a NonConsultant Hospital Doctor and what you will contribute to the specialty. I want specialize in field of General surgery proceed to Orthopedics.. I am interested to work in Irish health system because of its higher standards of health care. This recruitment will help me to pursue my career in Ireland. So i am looking forward for your response.
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Section H - Additional Information Use this section to highlight any non-academic achievements, awards and any other additional information you think is relevant to your application. 4 weeks in Surgical Oncolgy from SHAUKAT KHANUM MEMORIAL CANCER HOSPITAL ,LAHORE in April 2009. 4 weeks in Cardiac Medicine& Cardiac Surgery from PAKISTAN INSTITUTE OF CARDIOLOGY, LAHORE in March 2009. CONFERENCES / SYMPOSIUM / SEMINARS: The 8th Shaukat Khanum Memorial Cancer Symposium held on February 2009 by The American Academy of Continuing Medical Education. 26-28,
3rd International Conference of Reproductive Health & ART held on February 6-8 , 2009. 4th Annual International Conference of Gastroenterology held on 29th January 2009.
page 9
Section I - Referees
Referee 1 Name : Title : Clinical Site : Dr Shahid Khatak General and Colorectal surgeon Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan Shaukat Khanum Memorial Cancer Hospital & Research Center, Johar Town Lahore, Pakistan Shaukat Khanum Memorial Cancer Hospital & Research Center, Johar Town Lahore, Pakistan +923449825678
Address 1 :
Address 2 :
Phone : Fax : E-Mail : Referee 2 Name : Title : Clinical Site :
shahidk@skm.org.pk
Dr Mohammad Salim Malik Gynaecologist Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan Shaukat Khanum Memorial Cancer Hospital & Research Center, Johar Town Lahore, Pakistan Shaukat Khanum Memorial Cancer Hospital & Research Center, Johar Town Lahore, Pakistan +923334232125
Address 1 :
Address 2 :
Phone : Fax : E-Mail : Referee 3 Name : Title :
drmsmalik47@gmail.com
Dr Ameer Afzal Assistant Professor,East surgical ward Mayo Hospital, Lahore, Pakistan
page 10
Clinical Site : Address 1 : Address 2 : Phone : Fax : E-Mail :
Assistant Professor,East surgical ward Mayo Hospital, Lahore, Pakistan Assistant Professor,East surgical ward Mayo Hospital, Lahore, Pakistan Assistant Professor,East surgical ward Mayo Hospital, Lahore, Pakistan +923009460301
naustysurgeon@gmail.com
page 11
Section J - Notes When your application form is received, we create a record in your name, which contains much of the personal information you have supplied. This personal record is used solely in processing your candidature and should you be successful certain information you provide will be forwarded to the employing organisation. Such information held is subject to the rights and obligations set out in the Data Protection Acts, 1988 & 2003. DATA PROTECTION ACTS 1988 & 2003 Accepted? Yes
Section K - Further documentation you could send on request Please indicate what supporting documents you have which you could send on request Certified copy of Medical Council Certificate of Registration or registration letter Certified copy of transcript of exam results from your Medical School / University Certified copy of other degrees / diplomas (if applicable) Others Please specify Yes Yes Yes Yes Conferences and Elective documents, ACLS and Trauma course.
Section L - Signature Name Date Dr Ch Muhammad Aqeel 04/05/2012
page 12
Section M Part 1 - Declarations
Declaration One - Garda/Police
Can you declare that you have not at any time been convicted (i.e. probation, fine, sentence, penalty) of a criminal offence (e.g. assault, public order, sexual assault) in the Republic of Ireland and/or in any other jurisdiction nor are there any charges relating to criminal offences outstanding or pending; that you have never been the subject of a Caution or Bound over order? Yes Name Date Dr Ch Muhammad Aqeel 04/05/2012
Declaration Two - Training Organisation / Programme
Can you declare that you are currently not nor were you the subject of an investigation by any professional medical training body or its equivalent in the Republic of Ireland and/or in any other jurisdiction? Yes Name Date Dr Ch Muhammad Aqeel 04/05/2012
Declaration Three - Medical Council / Licensing Body
Can you declare that you have not at any time been convicted (i.e. probation, fine, sentence, penalty) of a criminal offence (e.g. assault, public order, sexual assault) in the Republic of Ireland and/or in any other jurisdiction nor are there any charges relating to criminal offences outstanding or pending; that you have never been the subject of a Caution or Bound over order? Yes Name Date Dr Ch Muhammad Aqeel 04/05/2012
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Section M Part 2 - General Declarations Name Date Dr Ch Muhammad Aqeel 04/05/2012
page 14
Section A - Hospital Group = Hospital / Mental Health Service (Ticked on Original Application Form)
page 15

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NCHD Application Form

Candidate ID: 024279809