Clinical Attachment Application Form

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Application for the Royal Liverpool & Broadgreen University
Hospital Clinical Attachment Scheme
Please, fill in this form and email it along with your CV to:
[email protected]
Surname:
Forename:
Sex:
Date of Birth:
Contact Address:
Contact Tel no: Home:
Mobile:
Email address:
Nationality:
Immigration status (delete if not applicable):
Has right of residence EU National
Refugee Tier 1 Tier 2 Student
other (specify)
Medical School from which
you have graduated:
Year of graduation:
Preferred specialty:
Name of a consultant who may have agreed to supervise you:
Consultant’s email address:
Signature:
Date:
HSMP
Visitor
For Office use only:
Approved: Yes
No
Reasons for not being approved:
Has not passed PLAB Test 1 & 2
IELTS 7.0 +
Primary Medical Qualification less than 4 years ago
Has had previous NHS Experience
Others:Important details to complete before confirming the placement:
Specialty:
Educational Supervisor:
Clinical Tutor:
Postgraduate Centre Manager:
HR Contact at the trust:
Duration:
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