Examination Application Form for FRCS (Ophthalmology) PART 2
FOR OFFICE USE ONLY Personal ID No:
_________________
Candidate Examination No: _________________
This form to be completed in full and returned to the Examination Unit, Royal College of Physicians and Surgeons of Glasgow, 232-242 St Vincent Street, Glasgow G2 5RJ, by the published closing date of entry. The examination fee and all relevant documentation should be included with the application. Cheques should be made payable to The Royal College of Physicians & Surgeons of Glasgow. Re-entrants need only complete, sign and date this page.
1.
Surname/Last name: .................................................................................... Other Name(s): ............................................................ Title: ....... Male / Female (delete as required) Address: Date of Birth: .../..../...
2. 3. 4.
PLEASE INCLUDE 2 PASSPORT PHOTOS
............................................................................................................................................................ ........................................................................................................ ..................................................................................................................... ......................................................................................................................
Postcode: Fax No: 5.
................................................. .................................................
Telephone No:
..............................................
e-mail address: .............................................. Date Conferred: ...../.../......
Primary Medical Qualification: .............................
University/Medical College: ..................................................................................................... Country of Qualification: ................................................. Provisional/Full (delete as appropriate)
GMC Registration No: (if applicable): 6.
Date and centre of examination for which candidate wishes to appear : Date:../.../... Centre:
7. Have you previously entered an examination through this College? YES/NO If Yes, Date:.../.../... Cand No: or ID Number: Date:../...../.....
8. Details of passing Part 1 or Part A FRCS Ophthalmology: Place:......
or Having an equivalent exemption (give details): Name: .. Awarding College: . Country: 9. Details of passing ICO Clinical Examination (if applicable): Place: ... Date:...../...../..... Date:...../...../.....
First Time entrants must attach evidence in support of Section 5 and Section 8 (original certificates or attested copies) 10. DECLARATION (To be signed by ALL candidates)
I have read the current Regulations of this examination and understand the eligibility criteria and I now confirm that to the best of my knowledge all the information given on this form is a true statement of fact. Signature of Applicant: ............................................................................... Date: ...../...../..
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11. CLINICAL EXPERIENCE
Candidates must submit full details of their clinical experience since graduation up to the present time as required under the Regulations, this included providing information on your pre-registration/internship year. (i) One year of pre-registration training:
Specialty & Grading Start Date End Date Duration (months) Signatures of Hospital Official
Name & Address of Hospital
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Please note that your pre-registration year cannot be included towards the required 5 years of clinical experience.
ii)
Clinical experience
Specialty & Grading Start Date End Date Duration (months) Signatures of Hospital Official
Name & Address of Hospital
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Total months
Notes for Section 11: i) If you are unable to obtain signatures on the actual form, the relevant details must still be entered on the form and letters or certificates of verification attached. Only originals or certified photocopies will be accepted. Please note: Certified copies will not be returned unless specifically requested. All original documents will be returned. ii) Details of clinical experience must be details of actual posts held. It is not enough to say MS Ophthalmology
12. Have you worked in a hospital in the West of Scotland before?
YES / NO (delete as appropriate)
If so, give details: Name of Hospital(s) .... Dates .
13. DECLARATION TO BE SIGNED
This form must be signed by two persons, Fellows or Members of the Royal College of Physicians and Surgeons of Glasgow OR Fellows of a College of Surgeons in the British Commonwealth OR Fellows or Members of a College of Physicians in the British Commonwealth. We hereby certify that: ..(Name of Candidate) is personally known to us and that we consider him/her to be in every way a suitable person for admission to the Surgical Fellowship of the Royal College of Physicians and Surgeons of Glasgow. i) Name (Block Capitals) Qualification Position Held .. Hospital . Signature .. Date:...../../..
ii) Name (Block Capitals) Qualification Position Held .. Hospital . Signature .. Date:...../../..
EQUAL OPPORTUNITIES MONITORING (OPTIONAL) The Royal College of Physicians and Surgeons of Glasgow aim to ensure fair treatment in relation to admission and assessment of examination candidates. The College aims to assess candidates on the basis of ability, regardless of gender, colour, ethnic or national origin, race, disability, age, socio-economic background, religious or political beliefs, family circumstances, marital status, sexual orientation or other irrelevant distinction. Completing this form will allow us to monitor our statistics and ensure that we are not discriminating in any way. In line with UK legislation and good practice guidelines, we are asking everyone to complete this section. You are not obliged to provide any of the information in this section, but if you do so, it will enable us to monitor our business processes and ensure that we provide equality of opportunity to all. Gender Female Male Nationality .. 1 language ... Do you have a disability under the terms of the Disability Discrimination Act 1995 (a person with a physical or mental impairment that affects your ability to carry out normal day to day activities which are substantial, adverse and long term)? Yes No
st
Ethnicity Choose one selection from the list below to indicate your cultural background. a) b) c) d) White British Irish Any other White background Mixed White and Black Caribbean White and Black African White and Asian Any other mixed background Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background Black or Black British Caribbean African Any other Black background
What is your sexual orientation? Bisexual Hetrosexual Lesbian or Gay
What is your religion or belief? Buddhist Christian Hindu Jewish Muslim Sikh Other religion/belief
e) Chinese or other ethnic group Chinese Any other background f) Middle East/Arabic Arabic Any other Middle Eastern background Indicate a more specific category here: ___________________________________
Indicate a more specific category here: ___________________________________
This information will be recorded electronically with your other data in accordance with the Data Protection Act 1998, but used only for monitoring our business practices.
METHOD OF PAYMENT All sections must be completed Name of candidate (BLOCK CAPITALS): ________________________________________ Examination: _______________________________ Date: _________________________ Payment must be made in full by (tick as appropriate): Bank draft Cheque Credit Card Debit Card BANK DRAFTS/CHEQUES: Bank drafts or cheques should be made payable to: The Royal College of Physicians and Surgeons of Glasgow. CREDIT/DEBIT CARD I wish to pay by: Visa (tick as appropriate)
Mastercard
Switch/Debit Card
Please note: We do not accept American Express, Diners Card or Solo. Card Number:
Valid from date: ___/____ mm / yy Issue number (if applicable): _______
Expiry date: ___/____ mm / yy Amount authorised to be withdrawn: ________
Amount in words: ___________________________________________________________ For details of current examination fees, please refer to the examination calendar at www.rcpsg.ac.uk. Name on card: ______________________________________________________________ (please print the name as it appears on the card) Name of cardholder: _________________________________________________________ (Block Capitals) Signature of cardholder: ______________________________________________________ Date: ___ / ___ / ___ (day/month/year) The method of payment form should be completed by all candidates and must accompany your application form to reach the College by the closing date for applications. Failure to complete any part of this form may delay the application process and may result in you being unable to sit the examination at the requested diet. WITHDRAWALS Any candidate withdrawing an application for admission to an examination must do so in writing. Provided such a withdrawal is received before the application closing date, a full refund of the examination fee will be issued, less an administration fee. After the application closing date, refund of the fee will not normally be made to a candidate who withdraws or fails to attend.
FRCS Ophthalmology Part 2 Guidenotes and Checklist for applicants Please use the notes and checklist below to ensure that your application is correctly completed and that you have enclosed all the required documentation. You must meet all the examination requirements at the time of application: incomplete applications or applications from those who are not eligible to sit will be returned. Please see the Dates, Fees and Centres document on our website for details of each examination. Please also read the document on application procedure. Should you have any questions prior to submitting your application please contact us: frcs@rcpsg.ac.uk All applications should be completed in BLOCK CAPITALS and should be written clearly and legibly. Re-entry If you have previously sat or been accepted for the Part 2 or Part B (April 2003 November 2009) examination you need only submit the following: Completed application form - signed and dated first page only Fee (amount due can be found on our website) Photographs (2 x passport size)
The only other documentation which may be required is the ICO Clinical Sciences certificate if you have sat and passed this examination since your last FRCS application. If your last application was for the Part B examination and it was accepted prior to April 2003 please complete the whole application form and attach the required documentation (see New Applicants). New Applicants If you are a new applicant please submit the following: Completed application form - signed and dated Fee (amount due can be found on the dates and fees link on our website) Photographs (2 x passport size) Degree certificate* Evidence of Part 1 Exemption* Evidence of Part 2 (multiple choice question paper only) Exemption* Evidence of Pre-Registration year/Internship* Evidence of Clinical Experience (either completed and signed Section 10 or attached letters)*
*All documents submitted should be in English and should be the original or preferably a certified copy of the original: uncertified photocopies will not be accepted. Photocopies of certified copies will not been accepted. Original certificates will be returned to you. Note: We do not require documents relating to courses attended or qualifications obtained prior to Primary degree.
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Notes on completion of application form: Section 1 - Name You will be registered in the name stated on your primary degree certificate. All documentation provided should be in this same name. If your name has changed we will require documentation giving details of this e.g. marriage certificate, affidavit. Any certificates received in a different name will not been accepted unless you provide documentation regarding a name change/alteration. Section 4 Contact Details Please ensure that your address is written clearly and in full. Your email address is important, as this is the easiest way for us to contact you. Please make sure that it is correct and legible. Section 5 Primary Qualification Your primary qualification is all that is required we do not need information on MS etc. The awarding institution should be recognised by the WHO and should appear on their list of approved medical institutions. If your awarding institution has changed its name it would be helpful if you could provide details of this. You must have been qualified for 6 years at the time of application to sit this examination. We calculate this from the date given on your degree certificate. Section 10 Declaration Your application is not complete and will not be accepted if this section has not been signed. Section 11 Clinical Experience We require evidence of posts held since qualification: this includes your pre-registration training (although this does not count towards your clinical experience). We are looking for clinical experience, not further qualifications. You should provide a start and end date and the title of the post held (not for example MS Ophthalmology). Where it is not possible for this section to be signed, a letter detailing all this information should be provided. Any letter provided should be signed, dated and be on hospital headed paper. Providing your MS certificate, for example, does not provide evidence of clinical experience and rarely gives specific start and end dates. What you should provide is evidence from the hospital in which you were working during this period. Any evidence provided needs to state a start and end date to enable us to calculate the total time achieved.
Checklist for Applicants Please ensure that you have enclosed with your completed application form:
Passport photographs x 2 Payment (credit card, bank draft or cheque) Evidence of degree degree certificate Evidence of Part 1 exemption Evidence of Part 2 (MCQ) exemption (if applicable) Evidence of pre-registration/internship year (if not detailed on degree certificate) Evidence of all clinical experience since graduation (start and end date required for each post) Change of name documentation marriage certificate/affidavit (if applicable)
We do not require any other documentation. All documents submitted should be in English and should be the original or preferably a certified copy of the original: uncertified photocopies will not be accepted. Photocopies of certified copies will not been accepted. Original certificates will be returned to you.
