RCVS Specialist 2016 for 2016/17 Listing

RCVS Specialist 2016 for 2016/17 Listing

RCVS Specialist 2016 for 2016/17 Listing

Application form for recognition/renewal of recognition of European Diplomates

Part A – Administrative details

Type information into the boxes, do not give attachments.

  1. Your name in full:

Surname: / First names: / Title: Prof/Dr/Mr/Mrs/Miss/Ms
  1. Name of speciality in which you wish to be recognised:
  1. Have you applied previously to RCVS for specialist recognition? (Delete as appropriate)

No / Yes / If Yes, please indicate when:
  1. Have you ever had a previous application for specialist recognition turned down by RCVS?

(Delete as appropriate)

No / Yes / If Yes, please indicate when:
  1. Contact details:

Registered address and telephone number / Address for communications concerning this application (if different)
Address:
Town:
County:
Postcode:
Daytime phone:
Email:
  1. Date you qualified:

Part B – Details of European Diploma and re-validation status

  1. Give details of the European Diploma that entitles you to be placed on the List of European Specialists. Indicate subject title of qualification and date awarded.

European College Diplomadate awarded

Have you previously supplied a copy of your qualification certificate to the RCVS? YES/NO

If you answered NO, please attach a copy of your qualification certificate

Current validation status date re-validation required

Please attach evidence of your current validation status

  1. Give details of your present appointment, including name, address and dates

Part C – References

References covering the professional skills requirement will need to be submitted where this is not a requirement of your European College. Please list the names, addresses and qualifications of two referees. Please ask your referees to provide a confidential reference for you using the prescribed form.

Letters of reference will not be accepted.

Please ask if your referee to complete the form and return it to the RCVS. Please ensure that you let your referees have sight of, or a copy of, your application, as they are asked, on the referee’s form, to confirm the accuracy of its contents.

Referee 1
Name, Address and Qualifications
Referee 2
Name, Address and Qualifications

Statement

I DECLARE that the information provided in this application is true.

Signature:
Name: (in capital letters)
Date:

Enclose the appropriate fee – Please refer to first page of application

Please submit:

  1. One electronic copy of your completed application
  2. Verification of the qualification you are offering by means of a copy of the Certificate from the European College if you have not already provided RCVS with this.
  3. Verification that you have re-validated with your European College, if applicable
  4. Two references, covering the professional skills requirement, where this is not a requirement of your European College. Signed references, either scanned and emailed to , or sent in sealed envelopes addressed to the Education Department at the RCVS.
  5. The fee relevant to your application - £40.