ࡱ> G bjbjƶ GnԬiԬi )D D 8"\~ f4&3333333$6B9 4 44 4F336/1#4'003640f40998191$ 4 4f49D X :   Faculty of Dental Surgery Application form for appointment to the Faculty of Examiners for the MEMBERSHIP IN * PLEASE INSERT HERE IN WHICH SPECIALTY YOU WISH TO EXAMINE Please present all your details in this form and do not send in supplementary information PLEASE COMPLETE AND RETURN AS SOON AS POSSIBLE PERSONAL DETAILS Surname: First names: Title: Date of birth: Home telephone: Email address: Mobile phone: Home address: Post code:  PROFESSIONAL DETAILS  GDC number: Fellow/Member of Ƶ: Roll Number: Or Date of Election:  Specialist list(s) or overseas equivalent:  PRESENT APPOINTMENT  Post: Date commenced: Hospital/Clinic: Telephone number: Fax number: Email address: Address: Post code: PREVIOUS POSTS   EDUCATIONQualifications obtained (include degrees, diplomas, and professional examinations)Exam/Qualifications (include awarding body)Year  TEACHING EXPERIENCE  EXAMINING AND ASSESSING EXPERIENCE Include membership or other examination boards, examinerships and responsibilities for education and training  General Experience Please give details of further experience that may be of relevance to the post of examiner   I confirm that I am: Please circle in active clinical or teaching practice Yes / No in good professional standing Yes / No completing CPD requirements Yes / No prepared to undergo training. Yes / No I confirm that I am not under any disciplinary investigation Signed Date  If appointed, I am prepared to serve on the Faculty of Examiners for a period of five years and to be actively involved in the examining process, including preparation of examination questions. Please note, the College reserves the right on occasion to validate an applicants declared CPD activity by asking for the submission of appropriate certification which it can verify. By signing below you agree that all information provided on the application form is correct and to the terms above. This form should be completed in TYPE. Forms completed by hand may not be accepted. PLEASE ENSURE THAT SIGNATURES ARE INK OR ELECTRONIC. ANY FORM WITHOUT A SIGNATURE OR WITH A TYPED SIGNATURE WILL NOT BE ACCEPTED. Signed: Date: Before sending in your application form, please ensure that you have included the following: Completed and signed application form Two completed and signed referee forms PLEASE RETURN COMPLETED FORM TO: - Dental Examiner Recruitment Examinations Section Nicolson Street EDINBURGH EH8 9DW Email:  HYPERLINK "mailto:dentalexaminerrecruitment@rcsed.ac.uk" dentalexaminerrecruitment@rcsed.ac.uk Tel: +44 131 527 1600 The final decision rests with Dental Council. 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