Form R: Registering for Postgraduate Specialty Training by HC120304231138

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									Form R: Registering for Postgraduate Specialty Training1



SHA:                                       Forename (s):

Deanery:                                   Surname:


Medical School awarding primary            Date of Birth:
qualification: (name and country)
                                           GMC/GDC Reg
                                                                     Attach Passport Size Photo
                                           No.:



Primary Qualification and date             Gender:
awarded:



Work Address:                              Home/Other Address:



                                           Home Phone:
Work Phone:                                Mobile Phone:
Email:                                     Email:


Immigration Status:                        Post Type or Appointment:
(e.g. resident, settled, work permit       (e.g. LAT, Run Through, FTSTA etc.)
required)



PMETB Programme Approval                   National Training Number:
Number:                                    (to be completed by Postgraduate Dean on first
(to be completed by Postgraduate           registration)
Dean)

                                           I confirm that I have been appointed to a programme
Deanery Reference Number:                  leading to award of a CCT subject to satisfactory
                                           progress                                          
Specialty:




1
 (to be confirmed on appointment to/on entering specialty training and before a National Training Number
(NTN) or Deanery Reference Number (DRN) is issued. Must be updated and submitted annually with the
Postgraduate Dean in order to renew registration for specialty training).

Form R                                                                                      Page 1 of 2
Specialty 1 for Award of CCT:            I confirm that I will be seeking specialist registration
                                         by application for a CESR       

Specialty 2 for Award of CCT:            I confirm that I will be seeking specialist registration
                                         by application for a CEGPR 


Provisional Date for                     Royal College/Faculty assessing training for the
CCT/CESR/CEGPR Award:                    award of CCT (if undertaking full prospectively
                                         approved programme):



Initial Appointment to Programme:        Date of Entry to Grade/Programme:
(Full time or % of Full time Training)   (Substantive date started in Programme of appointment)



I confirm that information recorded above is correct


Specialty Trainee: _______________________________                  Date: ______________

Postgraduate Dean/Head of School/

STC Chair/TPD:      _______________________________                 Date: ______________




Form R                                                                                Page 2 of 2

								
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