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First Name

Surname

Sex

Date of Birth

Nationality (as written on passport)

Medical Registration Number

Phone

Full title of Primary Medical Qualification (PMQ) / MBBS Degree

Name of institution where PMQ/MBBS Degree attained

Date Qualification Awarded

Level of English

Please provide details of your internship in the tables below

My internship was

Pre-graduate Post-graduate

Please provide details of each rotation below

Rotation 1

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 2

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 3

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 4

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 5

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 6

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 7

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 8

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 9

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

Rotation 10

Start Date

Finish Date

Speciality (e.g. surgery)

Hospital

You must include the following information:

All periods in the last five years where you were engaged in medical practice
All periods in the last 5 years when you were not employed in medical practice including: alternative employment; clinical attachments; vacation; study leave; maternity leave; career break or unemployment.

For each post that you were engaged in medical practice you must indicate:

The grade / title of the post
The speciality of the post
Whether the post was full time (FT) or part time (PT)
If part time, the number of hours of clinical practice you undertook each week

Work History 1

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 2

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 3

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 4

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 5

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 6

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 7

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 8

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 9

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Work History 10

Start Date

Finish Date

Name and location of Hospitals where you have worked or details for when you were not engaged in clinical practice

Country

Engaged in medical practice?

Yes No

Grade / Title of post?

Speciality

PT / FT

Part Time Full Time

Hours of clinical practice per week

Please provide all medical regulatory authorities that you have registered or held a licence with in the last five years as a doctor

Licensing History 1

Country

Medical Regulatory Authority

Start Date

End Date

Still registered / licensed?

Yes No

Licensing History 2

Country

Medical Regulatory Authority

Start Date

End Date

Still registered / licensed?

Yes No

Licensing History 3

Country

Medical Regulatory Authority

Start Date

End Date

Still registered / licensed?

Yes No

Licensing History 4

Country

Medical Regulatory Authority

Start Date

End Date

Still registered / licensed?

Yes No

Licensing History 5

Country

Medical Regulatory Authority

Start Date

End Date

Still registered / licensed?

Yes No

Is there anything else you would like us to know?

Please upload any relevant files or documents:

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