Board Or Panel Member Application Form

Board or Panel Member – Application Form

Please complete and return by email to by

Section 1

Contact details
Title:
Surname:
First name(s):
Post held:
Organisation:
Department:
Full postal address:
Postcode:
Country: ie England, Scotland, Wales, Northern Ireland
Telephone number:
E-mail address:

Section 2

Professional Details
Please attach a short CV (maximum of 3 pages).
Supporting statement
Please give a brief statement of your reasons for applying to become a member of the Health Services and Delivery Research Programme Board or Panel. Please refer to the role description.

Section 3

Please indicate if you would like your details to be kept in a pool of expert referees? / Yes / No
Please indicate if you would like your details to be kept in a pool of potential NETSCC Board or Panel Members? / Yes / No
Please confirm if you would like to join the HS&DR programme’s mailing list? / Yes / No
Confidential
Equal Opportunities (optional section) / The information provided in this section of the form is for monitoring purposes only.

Please tick as appropriate

What is your gender? / Female / Male
What is your date of birth?
What is your ethnic group (using the Census 2001 categories)? Please read the list below and tick one box that most nearly describes your ethnic origin.

1.  White

British / Irish
Any other White background. Please describe

2.  Mixed

White and Black Caribbean / White and Black African / White and Asian
Any other Mixed background. Please describe

3.  Asian or Asian British

Indian / Bangladeshi / Pakistani
Any other Asian background. Please describe

4.  Black or Black British

Caribbean / African
Any other Black background. Please describe

5.  Chinese or other ethnic group

Chinese
Any other ethnic group. Please describe
If you are disabled as defined by the Disability Discrimination Act what adjustments need to be made for the purpose of Board meetings?