Clinical Attachment Application Form Your details Note: Questions marked by * are mandatory Please refer to the privacy statement with how we store your data. *This is a mandatory field. Full Name *This is a mandatory field. Email Address *This is a mandatory field. Contact Telephone Number *This is a mandatory field. Immigration Status British Citizen Indefinite Leave to Remain Skilled Worker Visa Graduate Visa Student Visa EU Settlement Scheme Other - please specify below Please specify Visa Expiry Date (if applicable) *This is a mandatory field. Primary Medical Qualification *This is a mandatory field. Medical School / University *This is a mandatory field. Country of Qualification *This is a mandatory field. Year of Graduation *This is a mandatory field. GMC registration status Fully Registered Provisionally Registered PLAB completed, awaiting registration Not yet eligible *This is a mandatory field. GMC Number (if applicable). If you are not registered with the GMC, please enter 'Not Applicable' Yes No *This is a mandatory field. Have you completed PLAB Part 1? *This is a mandatory field. Have you completed PLAB Part 2? *This is a mandatory field. Please briefly summarise your relevant clinical experience since graduation. (Maximum 250 words.) *This is a mandatory field. Please briefly summarise any previous UK clinical experience (Clinical Attachments, Observerships, NHS Employment, Electives, etc.). If none, please write 'None'. (Maximum 200 words.) *This is a mandatory field. Why would you like to undertake a Clinical Attachment within our Trust, and what do you hope to gain from the experience? (Maximum 250 words.) *This is a mandatory field. Please summarise any teaching, research, audit, quality improvement, or leadership activities that demonstrate your commitment to professional development. (Maximum 250 words.) *This is a mandatory field. Please select your first choice specialty Please Select An Option Acute MedicineCardiologyEmergency MedicineEndocrinology and DiabetesENT surgery GastroenterologyGeriatric MedicineHaematologyIntensive Care MedicineNeurologyNeurosurgeryObstetrics & GynaecologyOncologyOphthalmologyOrthopaedicsPaediatricsRenal MedicineRespiratory MedicineRheumatologyStroke MedicineTrauma & OrthopaedicsUrologyVascular surgery Please select your second choice specialty Please Select An Option Acute MedicineCardiologyEmergency MedicineEndocrinology and DiabetesENT surgery GastroenterologyGeriatric MedicineHaematologyIntensive Care MedicineNeurologyNeurosurgeryObstetrics & GynaecologyOncologyOphthalmologyOrthopaedicsPaediatricsRenal MedicineRespiratory MedicineRheumatologyStroke MedicineTrauma & OrthopaedicsUrologyVascular surgery Please select your third choice specialty Please Select An Option Acute MedicineCardiologyEmergency MedicineEndocrinology and DiabetesENT surgery GastroenterologyGeriatric MedicineHaematologyIntensive Care MedicineNeurologyNeurosurgeryObstetrics & GynaecologyOncologyOphthalmologyOrthopaedicsPaediatricsRenal MedicineRespiratory MedicineRheumatologyStroke MedicineTrauma & OrthopaedicsUrologyVascular surgery *This is a mandatory field. Preferred Start Date (8 weeks notice required) *This is a mandatory field. Preferred Duration 4 Weeks 8 Weeks *This is a mandatory field. Please upload your current CV. Accepted formats: PDF, DOC, DOCX *This is a mandatory field. Please confirm that your attached CV includes the name, job title and professional email addresses for 2 referees Yes No * Spam Guard: Is a fire hot or cold?
