Application for Specialist Registrar Post

IRISH SURGICAL POSTGRADUATE TRAINING COMMITTEE

Specialty Training for Specialist Registrar in General Surgery Commencing July 2015

APPLICATION FORM (B)

This Application is for use by Candidates who commenced Basic Surgical Training before 1st July 2009 or Completed BST outside of Ireland

Standardised Selection Process for Route (B)

Closing Date: Friday 5th December 2014

This application must be submitted unbound and unstapled but in the correct order as per page numbers

Documents, with the exception of items under “Research and Academic”, will not be accepted after the closing date. There will be a provision for applicants to submit items such as Thesis, publications, presentations etc. that have been awarded after the closing date up until the date of the shortlisting meeting. Under NO circumstances will marks be given after the shortlisting meeting date based on accepted / awarded Thesis, Publications or Presentations. GUIDELINES General:

Application Fee: €100 Skills Assessment Fee: n/a Surgical AptitudeFee: n/a Commencement Date: July 2015 JCST Enrolment: Successful candidates will be required to enrol with the JCST Title of Post: Specialist Registrar (SpR) – General Surgery Duration of Programme: Six Years (subject to satisfactory continuous assessments) Curriculum: www.jcst.org Examinations: www.intercollegiate.org.uk

Approved Hospitals:

 Adelaide & Meath  Beaumont Hospital  Connolly Hospital INCH  Cork University  Drogheda/Dundalk  Kerry General Hospital Hospital  Letterkenny General  Mater Misericordiae  Mayo General Hospital Hospital Hospital  Mercy University  University Hospital  Sligo General Hospital Hospital Limerick  St. James’s Hospital  St. Luke’s Hospital  University College Hospital, Galway  St. Michael’s Hospital  St. Vincent’s  Portiuncula Hospital University Hospital  Waterford Regional  Wexford General Hospital Hospital

Additional hospitals may be approved during the course of your training. Successful candidates will be required to rotate to both University and non-University Hospitals throughout Ireland.

Entry Requirements:

. All applicants must hold the award of the CCBST or equivalent.

. All candidates must be registered with the Irish Medical Council (www.medicalcouncil.ie) or any other EU medical regulatory registration body.

. Please see important information regarding allocation of training places for 2015 at http://www.rcsi.ie/apply_st3

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland Selection Process:

The Standardised Selection Process (B) is available to download from http://www.rcsi.ie/apply_st3 All candidates are advised to familiarise themselves with this.

Applicants shortlisted for interview may be required to undertake an “Objective Assessment of Operative Skills” and a “Surgical Aptitude” test. All shortlisted candidates will be charged a fee for the objective assessment of operative skills.

Dates for your diary:

Closing Date: Friday 5th December 2014 Shortlisting Date: TBC Skills Assessment Date / Surgical Aptitude: TBC Interview Date: Week commencing March 23rd 2015

Completed applications to:

Denise Colgan Queries to:Denise Colgan National Surgical Training Centre Email: [email protected] RCSI Phone: 353-1-402 2188 123 St. Stephens Green Dublin 2 Ireland

Shortlisted applicants may be asked to submit verification of other documents outlined in the application form. Shortlisted applicants will be required to bring their official consoldiated logbook along to the interview.

Any attempt to provide misleading or false information to improve your score will result in automatic disqualification.

All information contained in this document is deemed to be a record held by RCSI and is subject to the provisions of the Freedom of Information Acts 1997 and 2003. The RCSI hold scanned copies of all applications for 1 year following the closing date. No originals are held or returned unless specifically requested by the applicant.

No deferrals of commencement of programme in July 2015 permitted.

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland SECTION ONE – PERSONAL DETAILS

APPLICANT DETAILS Title: ''Click here and type'' Surname: ''Click here and type Surname'' First Name: ''Click here and type Forename'' Date of Birth ''DD / MM / YY'' Nationality: ''xxxxxxxxxxxxxxxxxx'' Citizenship (if different from ''xxxxxxxxxxxxxxxxxx'' nationality):

''xxxxxxxxxxxxxxxxxx''

Country of graduation: ''xxxxxxxxxxxxxxxxxx'' Country where internship completed if ''xxxxxxxxxxxxxxxxxx'' different than country of graduation: Place of Birth: ''xxxxxxxxxxxxxxxxxx'' Address for Correspondence ''Click here and type Address'' ''Address line 2'' ''Address line 3'' ''Country'' Home telephone number ''xxxxxxxxxxxxxxxxxx'' Work telephone number ''xxxxxxxxxxxxxxxxxx' Mobile number: ''xxxxxxxxxxxxxxxxxx'' ' E-mail Address: ''Click here and type Email Address''

REGISTRATION DETAILS (Verification required, please refer to guidelines on our website) Registration Number ''xxxxxxxxxxxxxxxxxx'' Name in which you are ''Click here and type'' registered Type of registration (Tick one) Trainee Specialist Registration ''TICK ' General Registration ''TICK ' Registration Body (Tick one) Irish registration (IMC) ''TICK ' UK registration (GMC) ''TICK ' Other (please specify) ''Click here and type''

All applicants are required at the time of application to demonstrate their ENGLISH LANGUAGE COMPETENCY either by means of submitting the required IELTS Certificate / University of Cambridge Certificate in Advanced English documentation or by declaring themselves exempt under one of the exemptions outlined in the guidance document and providing the required documentary evidence of same (Please refer to guidelines on our website) Do you qualify under any four of the exemption grounds – YES or NO If Yes, which ground? Please ensure to provide documentary evidence

ENGLISH LANGUAUGE COMPETENCY (Verification Required, please refer to guidelines on our website) Page 4 of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland Tick appropriate box Country of graduation: ''TICK ' Registered with Medical Council prior to 9th July 2012 ''TICK ' Worked minimum 6 months as full time clinical NCHD since 9th July 2012 ''TICK ' Achieved Membership examinations ''TICK '

FELLOWSHIP / MEMBERSHIP OBTAINED (Please Specify) Date of Qualification Awarding College Qualification ''Click here and type Qualification'' ''Type Awarding Body'' ''DD / MM / YY'' ''Click here and type Qualification'' ''Type Awarding Body'' ''DD / MM / YY'' ''Click here and type Qualification'' ''Type Awarding Body'' ''DD / MM / YY''

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland SECTION TWO

A.1 CLINICAL SURGERY

1. SPECIALIST TRAINING UNDERTAKEN TO DATE

If you have completed or are currently in the process of undertaking structured specialist training under the formal auspices of one of the postgraduate medical training bodies for example RCSI BST (Basic Surgical Training) or other please enter the required details below.

Name of Training Body ''Click here and type name'

Full Name of Specialist Training Programme ''Click here and type name'

Date Specialist Training Programme Commenced ''Click here and type date'

Date of completion ''Click here and type date'

2. CERTIFICATE OF COMPLETION OF BASIC SURGICAL TRAINING (CCBST) (Verification required)

Date College

CCBST Certification Awarded ''DD / MM / YY'' ''Click here and type''

3. RECORD OF BASIC SURGICAL TRAINING (RCSI BST only)

Applicants who completed an RCSI Basic Surgical Training Programme are not required to submit their Trainer Assessment Forms as these are on file in the National Surgical Training Centre RCSI. If you completed an RCSI BST Programme please complete the following section

Region Start Date End Date

''Click here and type'' ''DD / MM / YY'' ''DD / MM / YY''

Office Use 1. ------2. ------3. ------4. ------

4. RECORD OF BASIC SURGICAL TRAINING (Other)

Applicants who did not complete an RCSI Basic Surgical Training Programme are required to submit Four Trainer Assessment Forms relating to their recognised BST Clinical experience (Senior House Officer- SHO). Please list the posts in which you carried out your Basic Surgical Training (blank Trainer Assessment Forms are available to download from http://www.rcsi.ie/apply_st3

Region Start Date End Date ''Click here and type'' ''DD / MM / YY'' ''DD / MM / YY'' ''Click here and type'' ''DD / MM / YY'' ''DD / MM / YY'' ''Click here and type'' ''DD / MM / YY'' ''DD / MM / YY'' ''Click here and type'' ''DD / MM / YY'' ''DD / MM / YY''

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland Structured References Forms

Applicants are required to ensure that three structured reference forms are submitted directly by the Referee to the Surgical Training Office before the 5th December 2014 (One Structured Reference Form must be from you current Trainer)

This is in addition to the 4 Trainer Assessment Forms relating to your recognised BST Clinical experience referred to in box (4) (if not completed through RCSI)

Structured Reference Forms can be located at http://www.rcsi.ie/apply_st3

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland 5. POST BASIC SURGICAL TRAINING – RELEVANT CLINICAL EXPERIENCE

Beginning with the most recent (i.e. current employment position) Please list all previous clinical appointments. In relation to each period of employment, you should highlight clinical experience relevant to this specialty/sub- specialty including Full -Time Clinical Surgical Posts or University Lecturer Posts

Clinical Site (If overseas please Grade Specialty Supervising From – To Months in post indicate country) Consultant

Surgery Example: 10/07/2011 - SHO (GS, T&O, Plastic Mr. Joe Bloggs 6 St. James’s Hospital 08/01/2012 etc)

''DD / MM / YY'' ''Click here and type ''Grade'' ''Speciality'' ''Consultant'' ''xx'' ''DD / MM / YY'' Information''

''Highlight clinical experience in the above post here"

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland 6. RECORD OF RELEVANT TECHNICAL SKILLS COURSES YOU HAVE COMPLETED

Course Date Venue ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type''

7. OTHER RELEVANT COURSES YOU HAVE COMPLETED

Course Date Venue ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type'' ''Click here and type'' ''DD / MM / YY'' ''Click here and type''

8. VALIDATED LOGBOOK / CONSOLIDATION SHEETS

Please complete and return validated consolidation sheet (template attached). (Please copy and paste sheet if required)

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland Consolidated Logbook Template (you must provide separate logbooks for BST & BSpT) Name: Specialty: P = to indicate that you performed the operation without senior supervision S = to indicate that you performed the operation with senior supervision A = to indicate that you assisted at the operation

Procedure Actual Actual Actual Number Number Number P S A ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type'' ''Click here ''Click here ''Click here ''Click here and type'' and type'' and type'' and type''

Please note your Logbook must be validated by your Consultant Trainer

Signature: ______Date: ______

Name: (Block Capitals) ______IMC Number: ______

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland A.2 RESEARCH AND ACADEMIC SURGERY

1. THESIS (VERIFICATION REQUIRED)

ECTS Office Use Please Tick University Credits

Thesis awarded by University? ''TICK ' ''Click here and type''

Thesis submitted to University? ''TICK ' ''Click here and type''

Documentation (receipt) of your thesis status much be submitted with this application

2. RELEVANT DEGREE/S YOU HAVE OBTAINED – PLEASE SPECIFY Date of Degree Awarding Body ECTS Office Use Qualification Credits ''Click here and type Qualification'' ''Type Awarding Body'' ''DD / MM / YY''

''Click here and type Qualification'' ''Type Awarding Body'' ''DD / MM / YY''

3. RELEVANT DIPLOMA/S YOU HAVE OBTAINED – PLEASE SPECIFY Date of Diploma Awarding Body ECTS Office Use Qualification Credits ''Click here and type name of exam'' ''Click here and type grade'' ''DD / MM / YY'' ''Click here and type name of exam'' ''Click here and type grade'' ''DD / MM / YY'' ''Click here and type name of exam'' ''Click here and type grade'' ''DD / MM / YY'' ''Click here and type name of exam'' ''Click here and type grade'' ''DD / MM / YY''

4. RELEVANT CERTIFICATES – PLEASE SPECIFY Date of Certificates Awarding Body ECTS Office Qualification Credits Use ''Click here and type name of exam'' ''Click here and type grade'' ''DD / MM / YY'' ''Click here and type name of exam'' ''Click here and type grade'' ''DD / MM / YY'' ''Click here and type name of exam'' ''Click here and type grade'' ''DD / MM / YY'' ''Click here and type name of exam'' ''Click here and type grade'' ''DD / MM / YY''

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland 5. PUBLICATIONS, BOOK CHAPTERS, PRESENTATIONS & TEACHING EXPERIENCE

Only complete these sections if they are applicable to you. Do not delete any pages. If you have more than one entry per category, copy and paste the relevant sections as needed.

Original Peer Reviewed Scientific Papers ( DO NOT INCLUDE ABSTRACTS)

If the Publication is not yet on P UB M ED There must be a letter of acceptance from the Editor of the Journal Submitted with the application PEER REVIEWED FULL LENGTH PAPERS Office Use Full descriptive title of published abstract ''Click here to start Typing''

Published in National Journal ''Type YES or NO'' Published in National Journal ''Type YES or NO'' – 1st Author Published in International Journal ''Type YES or NO'' Published in International Journal ''Type YES or NO'' – 1st Author Authors (Initial and surname only, no titles) ''Click here to start Typing'' Department(s), Institution(s), ''Click here to start Typing'' city(ies), country Name of Journal ''Click here to start Typing''

Volume and page number ''Click here to start Typing''

Publication date ''DD / MM / YY''

Impact Factor of Journal ''Click here to start Typing''

PEER REVIEWED FULL LENGTH PAPERS Office Use Full descriptive title of published abstract ''Click here to start Typing''

Published in National Journal ''Type YES or NO'' Published in National Journal ''Type YES or NO'' – 1st Author Published in International Journal ''Type YES or NO'' Published in International Journal – 1st Author ''Type YES or NO''

Authors (Initial and surname only, no titles) ''Click here to start Typing'' Department(s), Institution(s), city(ies), country ''Click here to start Typing''

Name of Journal ''Click here to start Typing''

Volume and page number ''Click here to start Typing''

Publication date ''DD / MM / YY''

Impact Factor of Journal ''Click here to start Typing''

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland 6. BOOK CHAPTERS – no marks awarded unless ISBN number is included.

7. INVITED REVIEW ARTICLES IN PEER REVIEW JOURNALS– points only awarded for 1st authorship. Author/s Office Chapter Title Book Title Publisher Date & Pages ISBN In order Use Review Title PMID No. Author Status ''Click here to start ''Click hereJournal to ''Click here Referenceto ''Click here to ''Click here to ''Click here to Office Typing'' start Typing'' start Typing'' start Typing'' start Typing'' start Typing'' Use ''Click here to start ''Click here to ''Click here to ''Click here to ''Click here to ''Click here to ''Click here to start Typing'' ''Click here to start ''Click here to ''Click here to ''Click here to start Typing'' start Typing'' start Typing'' start Typing'' start Typing'' start Typing'' Typing'' start Typing'' start Typing'' Typing'' ''Click here to start ''Click here to ''Click here to ''Click here to ''Click here to ''Click here to Typing'' start Typing'' start Typing'' start Typing'' start Typing'' start Typing'' ''Click''Click here here to startto start Typing'' ''Click''Click here here to to''Click start here''Click to here''Click to here''Click to here''Click to here''Click to here''Click to herestart to Typing'' start Typing''Typing''start Typing''start Typing''start Typing''start Typing''start Typing'' Typing''start Typing'' ''Click here to start ''Click here to ''Click here to ''Click here to ''Click here to ''Click here to ''Click hereTyping'' to start Typing'' start''Click Typing'' here tostart start Typing''''Click herestart to Typing''''Click herestart to Typing''''Click herestart to Typing'' start ''Click here to start ''Click hereTyping'' to ''Click here startto Typing''''Click herestart to Typing''''Click here to Typing''''Click here to Typing'' start Typing'' start Typing'' start Typing'' start Typing'' start Typing'' ''Click''Click here here to startto start Typing'' ''Click''Click here here to to''Click start here''Click to here''Click to here''Click to here''Click to here''Click to here''Click to herestart to Typing'' start Typing''Typing''start Typing''start Typing''start Typing''start Typing''start Typing'' Typing''start Typing''

''Click here to start ''Click here to start ''Click here to ''Click here to ''Click here to start Typing'' Typing'' Typing'' start Typing'' start Typing'' ''Click here to start ''Click here to start ''Click here to ''Click here to ''Click here to start Typing'' Typing'' Typing'' start Typing'' start Typing'' ''Click here to start ''Click here to start ''Click here to ''Click here to ''Click here to start Typing'' Typing'' Typing'' start Typing'' start Typing''

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland 8. CASE REPORTS 9. PRESENTATIONS – INTERNATIONAL Title Journal Reference PMID No. Author Status Office Name of Meeting Title Presentation Office Date Venue Use Use ''Click here to start Typing'' ''Click here to ''Click here to start ''Click here to ''Click here to start start''DD Typing'' / MM / ''ClickTyping'' here to start start Typing'' ''Click here to start Typing'' YY'' Typing'' ''Click here to startTyping'' Typing'' ''Click here to ''Click here to start ''Click here to ''Click here to start Typing'' ''Click here to start start''DD Typing'' / MM / ''ClickTyping'' here to start start Typing'' ''Click here to start Typing'' YY'' Typing'' ''Click here to startTyping'' Typing'' ''Click here to ''Click here to start ''Click here to ''Click here to start Typing'' ''Click here to start start''DD Typing'' / MM / ''ClickTyping'' here to start start Typing'' Typing'' ''Click here to start Typing'' YY'' Typing'' ''Click here to start Typing'' ''Click here to ''Click here to start ''Click here to ''Click here to start Typing'' ''Click here to start start Typing'' Typing'' start Typing'' ''DD / MM / ''Click here to start Typing'' ''Click here to start Typing'' YY'' Typing'' ''Click here to start Typing'' ''Click here to ''Click here to start ''Click here to ''Click here to start Typing'' ''Click here to start start Typing'' Typing'' start Typing'' ''DD / MM / ''Click here to start Typing'' ''Click here to start Typing'' YY'' Typing'' ''Click here to start Typing'' ''Click here to ''Click here to start ''Click here to ''Click here to start Typing'' ''Click here to start start Typing'' Typing'' start Typing'' ''DD / MM / ''Click here to start Typing'' ''Click here to start Typing'' ''Click hereYY'' to ''Click hereTyping'' to start ''Click''Click here hereto to start Typing'' ''Click here to start Typing'' ''Click here to start start Typing'' Typing'' start Typing'' ''DD / MM / ''Click here to start ''Click here to startTyping'' Typing'' ''Click here to start Typing'' YY'' Typing''

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland 10. PRESENTATIONS – NATIONAL

Name of Meeting Date Venue Title Presentation Office Use ''Click here to ''Click here to start Typing'' ''Click here to start Typing'' ''DD / MM / YY'' start Typing''

''Click here to ''Click here to start Typing'' ''DD / MM / YY'' ''Click here to start Typing'' start Typing''

''Click here to ''Click here to start Typing'' ''DD / MM / YY'' ''Click here to start Typing'' start Typing'' No points are awarded for poster presentations. Each Specialty will produce its own list of recognised scientific meetings.

PRIZES AND RESEARCH GRANTS

11. INTERTNATIONAL RESEARCH Office Date Amount Prizes /Grants Use ''Click here to start Typing'' ''DD / MM / YY'' ''Click here to start Typing''

''Click here to start Typing'' ''DD / MM / YY'' ''Click here to start Typing''

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland 12. NATIONAL RESEARCH Prizes /Grants Date Amount Office Use

''Click here to start Typing'' ''DD / MM / YY'' ''Click here to start Typing''

13. ADDITIONAL INFORMATION

If you wish to include any additional information relating to your application please use space provided i.e. Teaching Experience, membership of societies, management experience – please give details

''Click here''

REFEREES

Please give the name, job title and address of the three referees who will provide you with a reference. One of these referees must be your present or most recent supervising consultant.

Please note that all referees must use the standard reference template provided by the RCSI. All references must be supplied directly in an enclosed envelope to the National Surgical Training Centre.

Referee Number One Referee Number Two Referee Number Three Name: ''Click here and type name'' Name: ''Click here and type Name: ''Click here and type name'' name'' Title: ''Click here and type title'' Title: ''Click here and type title'' Title: ''Click here and type title'' Clinical Site: ''Click here and type Clinical Site: ''Click here and type Clinical Site: ''Click here and type clinical site'' clinical site'' clinical site'' ''Click here and address line 1'' ''Click here and address line 1'' ''Click here and address line 1'' ''Click here and type address line 2'' ''Click here and type address line ''Click here and type address line 2'' 2'' Phone: ''xxxxxxxxxxxxxxxx'' Phone: ''xxxxxxxxxxxxxxxx'' Phone: ''xxxxxxxxxxxxxxxx'' Fax: ''xxxxxxxxxxxxxxxx'' Fax: ''xxxxxxxxxxxxxxxx'' Fax: ''xxxxxxxxxxxxxxxx'' E-mail: ''xxxxxxxxxxxxxxxx'' E-mail: ''xxxxxxxxxxxxxxxx'' E-mail: ''xxxxxxxxxxxxxxxx''

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland 14. EXTRA CURRICULAR INTERESTS, HOBBIES

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland Application Checklist Please ensure that these supporting documents have been enclosed with your application. Failure to submit or enclose the required documentation may affect your overall score. Applications or parts of applications are not accepted by email or fax. ''TICK ' Application Form (Unbound and unstapled in correct order as per page numbers) ''TICK ' 2 passport sized photographs ''TICK ' Signed, dated, consolidated logbooks (BST & BSpT must be presented separately) ''TICK ' Copy of current Medical Council Certificate of Registration

Certified copy of appropriate Certificate of Completion of Basic Surgical Training ''TICK ' Undertaken (e.g. CCBST) ''TICK ' 4 BST Trainer Assessment Forms (if you did not complete an RCSI BST Programme)

Certified copy of degrees / diplomas (if applicable) or Verification of Thesis awarded / ''TICK ' submitted (letter from research supervisor)

€100 application fee (payable to RCSI by cheque, bank draft or credit card (visa or ''TICK ' MasterCard only) – see authorisation form enclosed

Other (Please specify) ''TICK ' Colour copy of current passport bio page & proof of citizenship if different than nationality ''TICK ' on passport

Structured Reference Forms: It is the responsibility of the candidate to ensure that the structured reference forms (X3) are submitted directly by the Referee to the National Surgical Training Centre RCSI on or before the closing date

I confirm that I have organised for my Three Structured Reference Forms to be sent directly by my Referees to the National Surgical Training Centre (NSTC) Administration Offices ''TICK ' under separate cover

SIGNATURE

I declare that to the best of my knowledge and belief that all the particulars furnished in connection with this application are true and accurate. I understand that I may be required to submit documentary evidence in support of any particulars given by me on my Application Form. I understand that any false or misleading information submitted by me may render any offer of a training position and associated employment offers as null and void.

I confirm that I have reviewed the documents relating to: Allocation of Training Places 2015; Eligibility for the Trainee Specialist Division of the Register & English Language Requirements.

Signature: Date:

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland Credit Card Authorisation

Specialty Training Programme – General Surgery

July 2015 Intake

Name of Card Holder: ______

Name of Applicant (If different): ______

Type of Card (Please tick as appropriate): Visa  Mastercard 

Card Number: ______/ ______/ ______/ ______

Expiry Date: __ __ / __ __

CVV Security Code ______(last three digits on back of card)

Amount to Debit: €100.00 (application fee)

Signature: ______

If you have any queries on your credit card payment please contact:

Denise Colgan National Surgical Training Centre RCSI 123 St. Stephen’s Green Dublin 2 Telephone: 01 402 2188 Fax: 01 402 2459 E-mail: [email protected]

Quoting – Speciality Training Programme – General Surgery

Office use only: CODE ------/------/------Narrative:______

of 19 Application Form B July 2015 Specialty Training Programme Applicants who commenced BST before 2009 or completed BST outside of Ireland