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LONDON 2018 - 2019

Application No:
(Office use only) / Date of receipt:
  • Please enclose a current Curriculum Vitae (this should contain your postgraduate, clinical and practice environment experience).
  • Please also include a personal statement letter to act as support of your application

The closing date for Late Applicationsis:1st March 2018

Please complete all pages in BLOCK CAPITALS and tick boxes as appropriate

Title:
(Mr/Mr/Miss/Ms/Dr) / Surname: / Forename(s):
Gender (M/F):
FGDP(UK) Membership Number:
GDC Number:
CONTACT DETAILS
Daytime tel:
Evening/home tel:
Mobile tel:
E-mail address:
POSTAL ADDRESS – for preferred contact
House name/ number
Street name
Town
County
Postcode
QUALIFICATIONS
Date of qualification day/month/year:
Date you obtained the Certificate in Minor Oral Surgery
FURTHER POSTGRADUATE QUALIFICATION
Please provide details of the following
Degree/Diploma / Year / Awarding Authority
WORK EXPERIENCE
Practice experience/scope of practice
Scope of practice
Practice address (if not correspondence address)
Please describe your current practice in no more than 50 words
EXISTING ARRANGEMENTS
Where do you currently refer oral surgery cases that you do not want / are unable to treat?
Do you have an existing relationship with a practicing Specialist Oral Surgeon (who is on the GDC Specialist List of Oral Surgeons) or is an experienced SAS grade in a maxillofacial unit, or who currently holds an IMOS contract?
Should the college need to arrange a tutor for you, are you prepared to travel to the site of the specialist clinic/ centre?
If relevant, please enclose a letter from the nominated tutor confirming they are prepared to act as your tutor, and provide their name and address below.
The faculty will then provide them with full details of the tutor position
Name
Email Address
House Number
Address
Town
County
Postcode
Mobile tel:
Daytime tel:
Evening/home tel:
REFERENCES
Applicants are required to nominate two professional referees whom the FGDP(UK) may approach if required.
Name: / Name:
Address: / Address:
Postcode: / Postcode:
Office hours tel: / Office hours tel:
Email: / Email:
Fax no: / Fax no:
Professional Relationship: / Professional Relationship:
SPECIAL NEEDS
If you have any special needs owing to a disability or specific learning difficulty, please give details
DIETARY REQUIREMENTS
If you have any specific dietary requirements, please give details
THE FOLLOWING SECTION MUST BE SIGNED
I certify that the statements I have made on this form are correct
I confirm that, if admitted to the programme, I will conform to the FGDP(UK) regulations

SignatureDate

PLEASE NOTE THAT THIS COURSE IS TAUGHT EXCLUSIVELY IN ENGLISH AND CANDIDATES WILL BE REQUIRED TO READ LITERATURE AND COMPLETE ASSIGNMENTS IN ENGLISH

Please return your completed application to:

Education Officer, FGDP(UK), The Royal College of Surgeons of England, 35-43 Lincoln’s Inn Fields, London WC2A 3PE or e-mail to

Applications will be considered on the basis of clinical experience, qualifications and general merit. However, the number of places on the programme is limited.

The FGDP(UK) cannot, therefore, guarantee it will be possible to admit every suitably qualified applicant.

DATA PROTECTION ACT

This information will be held in accordance with the Data Protection Act used for the purposes of course administration relating to the Diploma in Primary Care Oral Surgery.

In line with UK legislation and good practice guidelines, we are asking everyone to complete this section. You are not obliged to provide any of the information in this section, but if you do so, it will enable us to monitor our business processes and ensure that we provide equality of opportunity to all.

Name: / Ethnicity
Choose one selection from the list below to indicate your cultural background:
a)White:
British
Irish
Any other White background
b) Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
c) Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
d) Black or Black British
Caribbean
African
Any other Black background
e) Chinese or other ethnic group
Chinese
Any other background
Indicate a more specific category here:
Gender:
Nationality:
1st Language:
Do you have a disability under the terms of the Disability Discrimination Act 1995 (a person with a physical or mental impairment that affects you ability to carry out normal day to day activities which are substantial, adverse and long term)?
Yes
No
What is your sexual orientation?
Bisexual
Heterosexual
Lesbian or Gay
What is your religion or belief?
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Other religion/belief
Indicate a more specific category here:

This information will be recorded with your other data in accordance with the Data Protection Act 1998, but used only for monitoring our business practices.